Liina Poder, MD, FSRU Professor of Clinical Radiology, Obstetrics and Gynecology, UCSF [email protected] CHALLENGING CASES: FEMALE PELVIS CASE 37 year old with incidentally found bladder mass during second trimester ultrasound.

T2 •Benign or malignant? •Biopsy during cystoscopy? 37 year old with incidentally found bladder mass during second trimester ultrasound. Managed expectantly. 3 weeks post partum.

T2 during pregnancy T2 post partum Same patient during pregnancy and post partum appearance of left uterosacral ligament.

T2 pregnant T2 post partum

•Differential Diagnosis? Same patient during second trimester presented with acute left lower quadrant pain. Concern for ovarian torsion.

•Equivocal US but torsion not excluded Non-contrast MRI revealed striking intra peritoneal hemorrhage. No cause was identified, left hemorrhagic cyst was suspected. Laparoscopic exploration reveled no clear cause biopsies taken of left adnexa revealed decidual reaction.

T1 T2 T1 + gad

Uterine artery PSA and bleeding secondary to decidual reaction in deep endometriosis in pregnancy

Emerg Radiol. 2017 Oct 6. Uterine artery pseudoaneurysm in the setting of deep endometriosis: an uncommon cause of hemoperitoneum in pregnancy. Feld Z, Rowen T , Callen A , Goldstein R , Poder L TEACHING POINTS: ▸ Young reproductive age female think uncommon presentation of common disease/Recognize Aunt Minnie when you see her ▸ Endometriosis “Many Faces”: endometriomas, deep endometriosis, decidual reaction, polypoid endometriosis ▸ Common location on deep endometriosis: rectovaginal septum and uterosacral ligaments (69.2%), vagina (14.5%), alimentary tract 9.9%), urinary tract (6.4%) ▸ DPE: subperitoneal invasion by endometriotic lesions that exceed 5 mm in depth ▸ Deep endometriosis MRI: “location”, low T2/masslike/spiculated, high signal T2 and T1 foci (endometrial glands), +/- enhancement ▸ Decidual Reaction: hormonal influence during pregnancy, solid nodules strikingly similar to uterine decidua on T2, high ADC/low diffusion MRI Imaging in Deep Pelvic Endometriosis: A Pictorial Essay Antônio Coutinho et al, RadioGraphics Vol. 31, No. 2: 549-567 Morisawa at al, J Comput Assist Tomogr 2014;38: 879–884) COMPARTMENTAL ANATOMY: Vesicouterine pouch Rectovaginal pouch

Vesicovaginal septum

Prevesical space Rectovaginal septum

Published in: "MR Imaging in Deep Pelvic Endometriosis: A Pictorial Essay"Antônio Coutinho RadioGraphics Vol. 31, No. 2: 549-567Copyright RSNA, 2011 T2

T2

Hydronephrosis due to DPE T2 COMPANION CASE Reproductive age female presented with rectal bleeding. T1 T2

+ GAD Cervical versus Rectal Cancer? POLYPOID ENDOMETRIOSIS

▸ Rare variant of benign endometriosis ▸ Imaging: solid appearing + flow (may not have obvious blood products characteristic to endometriomas) ▸ Pathology: more stromal elements, resembles proliferative or inactive endometrial stroma ▸ Surgery/Colonoscopy: polypoid masses Polypoid Endometriosis

A Clinicopathologic Analysis of 24 Cases and a Review of the Literature Robin L. Parker, MD,* Farnaz Dadmanesh, MD,† Robert H. Young, MD,‡ and Philip B. Clement, MD§ SAM 1 30 year old with incidental finding on pelvic ultrasound for “pelvic pain” T2

T2 T1 + Gad SAM 1 30 year old with incidental finding on pelvic ultrasound for “pelvic pain”. Based on given information what is the most likely diagnosis?

A. Bladder leiomyoma B. Paraganglinoma C. Neurofibroma D. Endometriosis

Published in: "MR Imaging in Deep Pelvic Endometriosis: A Pictorial Essay"Antônio CoutinhoRadioGraphics Vol. 31, No. 2: 549-567Copyright RSNA, 2011 SAM 2

30 year old 24 weeks pregnant with superficial right abdominal pain worse during last weeks of pregnancy What is the most likely diagnosis? in phase

out of phase T2 30 year old 24 weeks pregnant with superficial right abdominal pain worse during last weeks of pregnancy What is the most likely diagnosis?

A. Rectus intramuscular hematoma B. Schwannoma C. Neurofibroma D. Decidual reaction in endometriotic implant

Poder L, Coakley FV, Rabban JT, Goldstein RB, Aziz S, Chen LM. Decidualized endometrioma during pregnancy: recognizing an imaging mimic of ovarian malignancy. J Comput Assist Tomogr. 2008 Jul-Aug;32(4): 555-8. Morisawa at al, J Comput Assist Tomogr 2014;38: 879–884) CASE 2 29 year old with acute right lower quadrant pain, 23 weeks pregnant with mono-di twins.

4x5.7x4.1 cm 4x2.7x1.9 cm CASE

US could not see appendix. Clinically unclear appendicitis vs ovarian torsion. Mild white count, nausea. Joint case with general surgery and gynecology. Urgent laparoscopy surgery: nl appendix, enlarged rt ovary, purple streaked and edematous, twisted 180 degrees around pedicle. Untwisted with return of normal color. rt ovary CASE 2 COMPANION

rt ovary

left ovary TEACHING POINTS: ▸ Ovarian torsion in pregnancy: 20% occurs in pregnancy (first/ second trimester - ligamentous laxity and physiologic stimulated ovaries/CL/dermoid cyst), > 4- 5 cm, rt > lt ▸ Ovarian torsion: Morphology/asymmetry (edematous storma/follicles pushed to the periphery trumps doppler, about 60% with normal doppler), twisted vascular pedicle harder to find during pregnancy ▸ Any adnexal mass in pregnancy: >6 cm high likelihood of developing torsion during first or second trimester ▸ If US equivocal: MRI non-contrast (ACR "green light" throughout pregnancy if indicated 1.5-3T)

Pearls and Pitfalls in Diagnosis of Ovarian Torsion , Hannah C. Chang et al Radiographics September-October 2008 28:1355-1368 COMPANION CASE 39 year old at 23 week anatomy scan with incidental ? right adnexal mass on US (nontender).

rt ovary

T1 left ovary

T2 rt ovary Massive ovarian edema: T2 managed expectantly, resolved post partum TEACHING POINTS MOE:

▸ Massive Ovarian Edema: Unilateral Subacute/chronic partial ovarian torsion described during pregnancy (flow present but ovary can be very swollen, teardrop appearance on MRI), non- tender ▸ T1 hemorrhage (more likely torsion) vs no T1 hemorrhage (MOE) ▸ +Twisted vascular pedicle (true torsion) ▸ MOE adjacent compression of uterus/lymphatic obstruction (rare but in differential tumor infiltration) ▸ Expectant management favored, consult experienced ob/gyn Coackley et al, J Comput Assist Tomogr. 2010 Nov-Dec;34(6):865-7 ANOTHER CASE 2 COMPANION 32 year old (not pregnant) with chronic abdominal pain for 3 month, low grade fever. Outside ultrasound with rt ovarian vascular mass and ? duplicated uterus.

terminal ileum

left ovary rt ovary

T2 inflamed appendix T2

inflamed appendix inflamed appendix

rt ovary T2 T1 post TEACHING POINTS MOE:

▸ Massive Ovarian Edema: Out of proportion enlarged ovary, no pain and presence of flow think MOE due to other rare causes rather than torsion ▸ In this case massive ovarian edema due to subacute appendicitis ▸ MRI can be helpful modality to complement US findings in pregnant or non pregnant patient

Emerg Radiol. 2017 Apr;24(2):215-218. Massive ovarian edema, due to adjacent appendicitis. Callen et al CASE 37 year old at 23 weeks presented with acute right lower quadrant pain. Right ovary 6x 2.6 x6.3 cm, tender and no doppler flow. 37 year old at 23 weeks presented with acute right lower quadrant pain. Right ovary 6x 2.6 x6.3 cm, tender and no doppler flow. MRI shows edematous ovary with internal hemorrhage with twisted vascular pedicle. rt ovary

rt ovary rt ovary lt ovary T1

T2 T2 EXAMPLES WHEN MRI IMPORTANT ADJUNCT TO US:

33year old with acute right 36 year old with acute RLQ pain, abdominal pain, 14w 3 days nausea and vomiting. US with pregnant. Pelvic and abdominal edematous ovary but unclear if rt US neg acute findings. adnexal mass versus uterine/BL in origin.

dermoid cyst fibroma

twisted vascular pedicle T2 lt ov T2 swollen ovary rt T2 T2 28weeks pregnant with RLQ pain and fever. Dif: torsed ovary, TOA, ruptured appy. MRI shows degenerating leiomyoma with bridging vessel sign. rt ov lt ov 20weeks pregnant left pelvic mass: ?origin rt adnexa lt ovary

T2 T2 FIRST TRIMESTER RT ADNEXAL MASS: FIBROMA (ON IMAGING SIMILAR TO FIBROID) diffusion ADC 41 year old woman, with incidental adnexal findings during 10 w ultrasound

Benign versus malignant? What is the next step? 41 year old woman, with incidental adnexal findings during 10 w ultrasound

Bilateral solid and cystic masses/thick septations/solid components/stained glass appearance on T1/T2 Bilateral borderline serous T2 tumor on path

T2 T1 26 year old woman, with incidental adnexal findings during 10 w ultrasound

T2

T2 T2 Diffusion OPTIMAL TIME FOR NON EMERGENT SURGERY DURING PREGNANCY ▸ Second trimester 16-20 w, organogenesis is complete, minimizing the risk of drug induced teratogenesis ▸ The hormonal function of the corpus luteum replaced by the placenta, reduction in progesterone secretion from oophorectomy or cystectomy does not affect progesterone concentration ▸ Almost all functional cysts will have resolved by this time ▸ The risk of pregnancy loss related to second trimester surgery is low ▸ Spontaneous pregnancy losses due to intrinsic fetal abnormalities are likely to have already occurred and will not be erroneously attributed to the surgery

Hoover K1, Jenkins TR, Evaluation and management of adnexal mass in pregnancy.Am J Obstet Gynecol. 2011 Aug; 205(2):97-102 MRI IN PREGNANCY PRACTICAL APPROACH

Placental/Uterine Acute Abdominal/ Incidental Adnexal Abnormalities Pelvic Pain masses

Adnexal: Ovarian Benign:Theca Lutein Accreta/Increta/ Torsion, Massive cysts, Endometriosis, Percreta Ovarian edema Fibroids

GI: Appendicitis, SBO, Subchorionic bleed, IBD, Cholecystitis, Decidual reaction Abruption Placentae Pancreatitis

Degenerating fibroids GU: Stones, Infection Malignant vs B9 CASE

24 year old female presented to ED with chronic intermittent RLQ pain, R/O appy versus ovarian torsion CT scan ordered. LO

CT read: - Neg for Appy Lt ovary normal HU 25 9 cm cystic structure (25 HU) in the pelvis, ?RO ? ovarian rec US to further evaluate LO

RO US: edematous rt ovary up to 9.5 cm with peripheralization of follicles and twisted vascular pedicle, + flow. Most likely intermittent torsion.

Surgery: Torsed rt ovary180, untwisted. Very edematous ovary Subsequent intermittent can mimic fluid or cyst, torsions x3. Patient had recommend urgent oopexy and ovarian ultrasound (don’t wait!) wedge resection. CASE

17 year old with acute right pelvic pain, + N/V, fever, RO ruptured cyst, pain over transplanted kidney. 17 year old with acute right pelvic pain, +N/V, fever, RO ruptured cyst, pain over transplanted kidney. 17 year old with acute right pelvic pain, +N/V, fever, RO ruptured cyst, pain over transplanted kidney. Ruptured ovarian cyst + UTI and Pyelo

T2

T2

T2 CASE Young woman with incidental pelvic mass. Query endometrioma?

Path: Epidermoid cyst Ovaries seen separately unlikely adnexal pathology. GI/GU/Neuronal etiology in pelvis

T2

T1 UNICORN?

“A horse who bumped into an ice cream cone”