MAHESH SHETTY M.D;FRCR;FACR;FAIUM CLINICAL PROFESSOR OF RADIOLOGY BAYLOR COLLEGE OF MEDICINE

GYNECOLOGICAL IMAGING GYNECOLOGICAL IMAGING CASE CONFERENCE

• Pelvic Mass • • Abnormal bleeding • Pregnancy of unknown location PELVIC MASS 36 F WITH LEFT PELVIC MASS AND PAIN

D/D

Tuboovarian abscess Dermoid ? Ovarian Neoplasm XANTHOGRANULOMATOUS OOPHORITIS

Large number of lipid laden Diverticulitis and or macrophages (foamy cells) PID may initiate together with lymphocytes, inflammatory plasma cells,epithelioid macrophages, fibroblasts process in the and neutrophils XGP OF OVARY Histological differential diagnosis Pathogenesis of the is fibrohistiocytic xanthogranulomatous process seems to be the consequence of tumors and spindle phagocytosis by macrophages cell carcinomas following hemorrhage,  Xanthogranulomatous and oophoritis secondary suppuration and necrosis to diverticulitis. A rare cause of postmenopausal bleeding. Jan 2007. Journal of Obstetrics and Gynecology 30 F RLQ PAIN, WITH HISTORY OF BEING TREATED WITH PELVIC RADIATION 10/96

9/97 PRESENTS WITH A LEFT FLANK MASS

OVARIPEXY

transposed to avoid radiation damage in women of reproductive age group  Initial scan showed a functional cyst in the right ovary  Subsequent scan shows a solid metastatic lesion in left ovary 36 YEAR OLD WOMAN WITH PELVIC MASS AND SEVERE LLQ PAIN

CT SCAN OF THE PELVIS DIAGNOSIS

Gastrointestinal with rupture GI TRACT ENDOMETRIOTIC IMPLANTS

12-37% of patients with endometriosis Rectosigmoid colon, appendix, cecum, distal ileum Usually serosal, can cause marked reactive thickening and fibrosis of muscularis propria COMPLICATIONS:  Adhesions, bowel strictures, GI obstruction D/D:  Metastatic disease (drop mets from upper GI primary,  Primary colon cancer Acute LLQ and pelvic pain, pelvic ultrasound shows a normal left ovary with flow A predominantly hyperechoic, mass like abnormality is seen in the LLQ CT SCAN

PRIMARY EPIPLOIC APPENDAGITIS

• CT FINDINGS • Pericolic, oval, fat-density lesion 1.5 to 3.5 cm in diameter with a hyper attenuated rim and peripheral fat stranding PRIMARY EPIPLOIC APPENDAIGITIS: • The epiploic appendages are fat-filled peritoneal outpouchings that protrude from the serosal surface of the colon. • Primary epiploic appendagitis (PEA) is an acute abdominal condition due to spontaneous torsion or venous thrombosis of an epiploic appendage, resulting in ischemia with secondary : RX? D/D ➢Acute sigmoid diverticulitis ➢Omental infarction 34 YR OLD WOMAN WITH A PELVIC MASS ON PHYSICAL EXAM Transabdominal pelvic ultrasound

DIAGNOSIS:

•PELVIC LIPOSARCOMA RETROPERITONEAL LIPOSARCOMA

95% OF FATTY RETROPERITONEAL TUMORS SECOND MOST COMMON RETRO- PRT TUMOR AFTER MALIGNANT FIBROUS HISTIOCYTOMA SLOW GROWING 12% CALCIFICATIONS MOST RADIOSENSITIVE OF THE SOFT TISSUE SARCOMAS

TYPES: PLEOMORPHIC: MUSCLE DENSITY 40-60% LIPOGENIC MYXOID:MUSCLE AND FAT DENSITY 41 F LEFT SIDED PELVIC PAIN AND MASS ENDOVAGINAL ULTRASOUND

DERMOID Diffuse or localized hypoechogenicity Cysts Shadowing echogenicity Hyperechoic lines and dots Fat fluid levels PAIN WHEN LAYING DOWN ,MRI SPINE WAS PERFORMED

Ultrasound shows a septated cyst BENIGN FUNCTIONAL CYST 32 F WITH A PELVIC MASS Normal left ovary and a solid mass adjacent to it T2 WEIGHTED AXIAL MR IMAGE

D/D of a Solid Most common is a pedunculated fibroid Endometrioma Solid ovarian neoplasm Brenner's Sex cord/stromal: fibromas, thecomas, Sertoli Leydig cell Metastasis PELVIC PAIN 42 F,FEVER ACUTE LLQ AND PELVIC PAIN LLQ,TRANSVERSE IMAGE LONG AXIS IMAGE LLQ

DIVERTICULAR ABSCESS 87 F LLQ PAIN LLQ ULTRASOUND

TRANSVERSE IMAGE PELVIC HEMOPERITONEUM CT SCAN PATIENT WAS ON COUMADIN CT Findings: • Circumferential wall thickening, intramural hyperdensity, luminal narrowing, and intestinal obstruction • Other causes: Hemophilia, ITP, Lymphoma,leukemia Spontaneous intramural small-bowel hematoma: imaging findings and outcome: AJR 2002 179;1389

• Mean age: 64 years • Excessive anticoagulation: Warfarin Rx:62% • Solitary lesion:85%,SBO:85%,CT diagnosed in 100%, spontaneous resolution, conservative Rx • 69% Jejunum, 38% ileum, Avg length: 23cm, shortest segment:8cm ABNORMAL BLEEDING 48 YR OLD WOMAN WITH ABNORMAL BLEEDING

DIAGNOSIS:

Polypoid adenomyoma with cystic degeneration Polypoid Adenomyomas: Sonohysterographic and Color Doppler Findings With Histopathologic Correlation Eun Ju Lee, MD, Jae Ho Han, MD, Hee Sug Ryu, MD. J Ultrasound Med 2004; 23:1421–1429 Polypoid adenomyoma of the , also known as an adenomyomatous polyp, is an in which the stromal component is predominantly or exclusively composed of smooth muscle. They are rare polypoid lesions, accounting for only 1.3% of all endometrial polyps Histologically, a typical Polypoid adenomyoma is composed of benign endometrial glands admixed with a benign-appearing smooth muscle stroma D/D: endometrial polyp, a submucous leiomyoma with cystic degeneration, or trophoblastic disease 41 F ABNORMAL BLEEDING ULTRASOUND SAGITTAL T2 WEIGHTED IMAGES POST CONTRAST AXIAL TI WEIGHTED IMAGE UTERINE AVM

CONGENTIAL ACQUIRED MRI is optimal is defining the extent of an uterine AVM FINDINGS:  Distinct serpiginous flow voids on T2 weighted sequence  Disruption of the junctional zone  Prominent parametrial vessels 49 F WITH ABNORMAL BLEEDING ENDOVAGINAL US MRI MRI CLEAR CELL ADENOCARCINOMA

The most common non-endometrioid histology is papillary serous (10%), followed by clear cell (2% to 4%), mucinous (0.6% to 5%), and squamous cell (0.1% to 0.5%) Some non-endometrioid endometrial carcinomas behave more aggressively than the endometrioid cancers such that even women with clinical stage I disease often have extrauterine metastasis at the time of surgical evaluation CANCER CONTROL. 2009 JAN;16(1):46-52 NON-ENDOMETRIOID ADENOCARCINOMA OF THE UTERINE CORPUS: A REVIEW OF SELECTED HISTOLOGICAL SUBTYPES

 High rate of recurrence, adjuvant therapy is recommended even in women with early-stage disease  There is association with Exposure to diethylstilbestrol in utero  More common in the ovary 41 F ABNORMAL BLEEDING ENDOVAGINAL US LIPOLEIOMYOMA Gynecol Obstet Invest. 2008;66(2):73-5. Lipoleiomyoma of the uterus: imaging features Extremely rare, benign, uterine tumor that requires no treatment when asymptomatic CT/MRI for confirmation PREGNANCY OF UNKNOWN LOCATION • Interstitial pregnancy : Gestational sac implants in the myometrial segment of the . • Cornual pregnancy refers to the implantation within the cornua of a bicornuate or Septate uterus. • An ovarian pregnancy occurs when an ovum is fertilized and is retained within the ovary. • Cervical pregnancy results from an implantation within the endocervical canal. • Scar pregnancy, implantation takes place within the scar of a prior cesarean section. • Intraabdominal pregnancy, implantation occurs within the intraperitoneal cavity. • Heterotopic pregnancy occurs when an intrauterine and an extrauterine pregnancy occur simultaneously 8 weeks pregnant, cramping • ENDOVAGINAL ULTRASOUND SHOWS AN HOUR GLASS APPEARANCE OF THE GESTATIONAL SAC LOCATED IN THE SAGITTAL T2 WEIGHTED IMAGE CERVICAL ECTOPIC

• It is rare (<1% of ectopic • In a cervical pregnancy, the uterus pregnancies) and is likely may be shaped like an hourglass associated with in vitro or a figure eight as the fetus fertilization and a history of expands within the cervix prior curettage • Cardiac activity below the internal os is highly suggestive of a cervical pregnancy INTERSTITIAL ECTOPIC PREGNANCY

•2%–4% of all ectopic pregnancies 6 WEEKS PREGNANT, ULTRASOUND • Arrowhead shows pseudogestational sac • Arrow shows the interstitial or cornual pregnancy 11 WKS IUP INTERSTITIAL PREGNANCY C-SECTION SCAR PREGNANCY PELVIC PAIN, POSITIVE PREGNANCY TEST ENDOVAGINAL SCAN SHOWS SCAR PREGNANCY C-SECTION SCAR PREGNANCY RADIOGRAPHICS. 2008 OCT;28(6):1661-71 DIAGNOSTIC CLUES TO ECTOPIC PREGNANCY

•2% of all pregnancies and is the most common cause of pregnancy- related mortality in the first trimester (9-14%) C SECTION SCAR ECTOPIC

•Caesarean scar pregnancies are rare •estimated to occur in less than 1% of all pregnancies POSITIVE PREGNANCY TEST 34 F 7 IUP

C SECTION SCAR PREGNANCY THANK YOU.

[email protected]