MAHESH SHETTY M.D;FRCR;FACR;FAIUM CLINICAL PROFESSOR OF RADIOLOGY BAYLOR COLLEGE OF MEDICINE GYNECOLOGICAL IMAGING GYNECOLOGICAL IMAGING CASE CONFERENCE • Pelvic Mass • Pelvic Pain • Abnormal bleeding • Pregnancy of unknown location PELVIC MASS 36 F WITH LEFT PELVIC MASS AND PAIN D/D Endometrioma 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 ovary 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 endometritis 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 Ovaries 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 endometriosis 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 inflammation: 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 adnexal mass 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 uterus, also known as an adenomyomatous polyp, is an endometrial polyp 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 fallopian tube. • 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 CERVIX 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. 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