NON OVARIAN ADNEXAL MASSES: DIFFERENTIAL DIAGNOSIS MAHESH K. SHETTY MD, FRCR,FACR, FAIUM CLINICAL PROFESSOR OF RADIOLOGY BAYLOR COLLEGE OF MEDICINE OZAT, M., ALTINKAYA, S.O., GUNGOR, T. ET AL. ARCH GYNECOL OBSTET (2011) 284: 713. HTTPS://DOI.ORG/10.1007/S00404-010-1705-9 Extraovarian conditions mimicking ovarian cancer: a single center experience of 15 years • Extra-ovarian diseases accounted for 5.11% (113/2,210) of all the cases. • 113 extra-ovarian diseases • 42 (37.17%) were peritoneal tuberculosis, • 25 (22.13%) were gastrointestinal malignancies, • 20 (17.70%) were pelvic abscess, • 8 (7.08%) were pelvic echinococcosis, • 8 (7.08) were schwannoma and other retroperitoneal tumors, • 4 (3.53%) were malignant lymphoma, • 2 (1.77%) were chronic ectopic pregnancy, MASCH, W.R., KAMAYA, A., WASNIK, A.P. ET AL. ABDOM RADIOL (2016) 41: 783 • Identify both ovaries as the presence of two normal ovaries makes a primary ovarian neoplasm very unlikely • Close attention to a pelvic lesion’s vascular supply and drainage pattern • Association with or displacement of other pelvic structures (e.g., bowel, uterus, bladder, pelvic sidewall, osseous structures, etc.) Feature Favors ovarian origin Favors extraovarian origin Peritoneal disease Soft tissue and ascites Soft tissue alone Ovarian mass(es) Normal ovaries Effect on pelvic sidewall Displaced laterally Displaced medially vasculature Encased by a soft tissue mass Cystic structure invaginates around centered in pelvis but does not displace structures OR solid mass centered outside of pelvis Effect on ureters Compressed, rarely encased May be encased, obstructed, or displaced medially Vascularity Exhibits washout kinetics of soft Enhancement matches pelvic tissue arteries in all phases Engorged gonadal vessels Engorged mesenteric vessels Calcification patterns Psammomatous or eggshell Coarse or trabecular Relation to small or large bowel Extrinsic compression or Encasement or inseparability, displacement especially from cecum BENIGN EXTRAOVARIAN MIMICS OF OVARIAN CANCER DISTINCTION WITH IMAGING STUDIES. LEVINE ET AL CLINICAL IMAGING 1997:21:350-358 • Complex Adnexal Cyst Vast majority of adnexal or Mass: masses surgically 10-15% are extraovarian removed are Dermoids, mimicking primary ovarian endometriosis or neoplasms functional cysts NON OVARIAN ADNEXAL PATHOLOGY •GYNECOLOGICAL •GASTROINTESTINAL •PERITONEAL/MESENTERIC • Identify a normal ovary separate from the abnormality • Supplemental imaging with MRI and CT is useful in the differential diagnosis NON OVARIAN ADNEXAL PATHOLOGY GYNECOLOGICAL • Simple distension of the • Fallopian Tube abnormalities tube: hydrosalpinx • Uterine abnormalities • Complex abnormalities of • Paraovarian Cysts the fallopian tube • Endometriosis Complex abnormalities of the fallopian tube • Pelvic Inflammatory Disease (PID) ➢Salpingitis ➢Pyosalpinx ➢Tuboovarian abscess • Hematosalpinx • Tubal torsion • Tubal malignancy FALLOPIAN TUBE PATHOLOGY • IN ONE STUDY 15 OF THE 21 HYDROSALPINGES WERE MISDIAGNOSED AS OVARIAN PATHOLOGY HYDROSALPINX • Tubular shape • Incomplete septations • Small endosalpingeal folds giving a ‘beads on string appearance’ • ‘Waist sign’ linear indentation of the wall of a cystic mass that has a corresponding indentation on the opposite wall of the mass HYDROSALPINX • Blockage occurs at the fimbriated end of the tube • Causes: PID and endometriosis • 8% of women with PID or endometriosis develop hydrosalpinx DISTENED FALLOPIAN TUBE: • Hydrosalpinx on a hysterosalpingogram ULTRASOUND:HYDROSALPINX NON OVARIAN ADNEXAL PATHOLOGY • Hydrosalpinx GYNECOLOGICAL • PID •Fallopian Tube ➢Pyosalpinx abnormalities ➢Salpingitis[TAO] •Uterine abnormalities ➢Tuboovarian Abscess •Paraovarian Cysts • Tubal Pregnancy •Endometriosis • Tubal Torsion • Tubal Malignancy RADIOGRAPHICS 2011; 31:527–548 •PID is infection of the upper female genital tract, resulting in a spectrum of abnormalities affecting the fallopian tube, including salpingitis, pyosalpinx, and tubo- ovarian abscess (TOA) PID: INDICATIONS FOR IMAGING • Non specific symptoms • No response to treatment • Assess complications such as abscess • US is optimal for identifying the ovaries and can be useful for differentiating among complications such as pyosalpinx and TOA SPECTRUM OF IMAGING FINDINGS IN PID • SALPINGITIS • TUBO-OVARIAN COMPLEX • PYOSALPINX • TUBOOVARIAN ABSCESS RIGHT SALPINGITIS RADIOGRAPHICS 2011; 31:527–548 • Further progression of infection and inflammation results in destruction of the normal structures with formation of an inflammatory mass encompassing both the fallopian tube and ovary. Rupture of a TOA may cause life-threatening peritonitis • Tubo-Ovarian Complex • Markedly thickened fallopian tube forming a Tuboovarian Phlegmon without an abscess PID: TUBOOVARIAN COMPLEX DISTENED FALLOPIAN TUBE: Hydrosalpinx Salpingitis [TAO] Pyosalpinx Tuboovarian Abscess Tubal Torsion Tubal Malignancy PYOSALPINX • More likely to be bilateral • Thickened fallopian tube • Small bowel ileus may be associated Hydrosalpinx Pyosalpinx Ectopic Pregnancy Tubal Torsion Tuboovarian Abscess Tubal Malignancy RADIOGRAPHICS 2011; 31:527–548 • Fitz-Hugh–Curtis Syndrome.— • One complication of PID is peritoneal spread of infection via the right paracolic gutter to involve the peritoneal surfaces of the right upper quadrant. The characteristic feature at surgery is “violin string” adhesions that extend from the anterior surface of the liver to the peritoneum. Fitz-Hugh–Curtis syndrome in a 28-year-old woman with PID and abnormal liver function test results. Rezvani M , Shaaban A M Radiographics 2011;31:527-548 ©2011 by Radiological Society of North America • Perihepatitis can be seen at contrast-enhanced CT as thickening and enhancement of the anterior liver capsule • Inflammation of the Glisson capsule can cause subcapsular and periportal geographic areas of perfusional variation • Gallbladder wall thickening may be present D/D HEMATOSALPINX •Tubal pregnancy •Tubal endometriosis •Tubal torsion •Tubal malignancy •Trauma HEMATOSALPINX: ENDOMETRIOSIS H/O EXTENSIVE ENDOMETRIOSIS RIGHT SIDED PELVIC PAIN, NEGATIVE PREGNANCY TEST MRI SHOWS TI HYPERINTENSE AND T2 ISO TO HYPOINTENSE ABNORMALITY HEMATOSALPINX RIGHT CHRONIC PELVIC PAIN CHRONIC TUBAL PREGNANCY TUBAL TORSION • Isolated fallopian tube torsion is exceedingly rare, occurring in only one of every 1.5 million women • Tubal torsion usually affects adolescent girls and women of reproductive age • Risk factors include a long or congested mesosalpinx, prior tubal ligation, hydatid cyst of Morgagni, hydrosalpinx, PID, hypermotility of the fallopian tube, and trauma. • Torsion of the right fallopian tube is much more common, a fact that is thought to be related to fixation of the left tube in the left hemipelvis by the sigmoid colon and mesentery RADIOGRAPHICS 2011; 31:527–548 • Fusiform tubal dilatation with tapered ends, free fluid, and surrounding inflammation • The fallopian tube may have thickened echogenic walls and internal debris • An edematous mesosalpinx may be seen as a central solid component surrounded by the dilated fallopian tube . • Identification of a normal ovary is helpful for confirming the tubal origin of the cystic mass. Fallopian tube torsion in a 19-year-old woman with gradual onset of lower abdominal pain (worse in the left lower quadrant) DILATED TUBULAR CYSTIC STRUCTURE (ARROW) WITH THICKENED OEDEMATOUS WALLS Rezvani M , Shaaban A M Radiographics 2011;31:527-548 ©2011 by Radiological Society of North America CT TUBAL TORSION • Multiplanar reformatted (MPR) images may be helpful in visualizing the tubular shape, tapered ends (“beak sign”), and twisted configuration of the mass • Intraluminal attenuation greater than 50 HU indicates internal hemorrhage. There may be secondary findings of free fluid, peritubal fat stranding, thickening and enhancement of the broad ligament, and focal reactive ileus Fallopian tube torsion in a 19-year-old woman with gradual onset of lower abdominal pain (worse in the left lower quadrant). Rezvani M , Shaaban A M Radiographics 2011;31:527-548 ©2011 by Radiological Society of North America DISTENDED FALLOPIAN TUBE: Hydrosalpinx Pyosalpinx Ectopic Pregnancy Tubal Torsion Tuboovarian Abscess Tubal Malignancy • Primary fallopian tube carcinoma is least common of all gynecologic malignancies, with an age-adjusted prevalence of 3.72 per 1 million women • prevalence of PFTC may be underestimated because of the difficulty in differentiating PFTC from epithelial ovarian carcinoma, especially in advanced cases. • A new theory suggests that the fimbrial end of the fallopian tube may be the origin of many, cases of aggressive serous ovarian carcinoma RADIOGRAPHICS 2011; 31:527–548 • Theory is based on histopathologic observations in BRCA-positive women who have undergone prophylactic salpingo-oophorectomy, in whom a high prevalence of occult PFTC ranging from 0.9% to 17% has been reported • The most common histologic type of PFTC is papillary serous carcinoma, which is histologically identical to serous ovarian adenocarcinoma. RADIOGRAPHICS 2011; 31:527–548 • Unlike with simple hydrosalpinx, which results from tubal obstruction by adhesions or debris, the tube is usually patent in PFTC, at least at one end • Gradual tubal distention results in colicky pelvic pain and eventual decompression of the tube and passage of fluid from either end, with shrinkage of the pelvic mass • PFTC is usually detected earlier than primary ovarian carcinoma and has a better prognosis, since patients seek medical attention