GYNECOLOGICAL IMAGING

MAHESH SHETTY M.D;FRCR;FACR;FAIUM

CLINICAL PROFESSOR OF RADIOLOGY

BAYLOR COLLEGE OF MEDICINE

GYNECOLOGICAL IMAGING CASE CONFERENCE

•Pelvic Mass

•Pelvic Pain

•Abnormal bleeding

•Pregnancy of unknown location

PELVIC MASS

36 F WITH LEFT PELVIC MASS AND PAIN

Endometrioma

Tuboovarian abscess

Dermoid

? Ovarian Neoplasm

D/D

Large number of lipid laden

macrophages (foamy cells)

together with lymphocytes,

plasma cells,epithelioid

macrophages, fibroblasts

and neutrophils

Diverticulitis and or

PID may initiate

inflammatory

process in the ovary

XANTHOGRANULOMATOUS OOPHORITIS

Pathogenesis of the

xanthogranulomatous process

seems to be the consequence of

phagocytosis by macrophages

following hemorrhage,

suppuration and necrosis

Histological

differential diagnosis

is fibrohistiocytic

tumors and spindle

cell carcinomas Xanthogranulomatous endometritis and oophoritis secondary

to diverticulitis. A rare cause of postmenopausal bleeding.

Jan 2007. Journal of Obstetrics and Gynecology

XGP OF OVARY

30 F RLQ PAIN, WITH HISTORY OF BEING

TREATED WITH PELVIC RADIATION

10/96

9/97 PRESENTS WITH A LEFT FLANK MASS

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

OVARIPEXY

36 YEAR OLD WOMAN WITH PELVIC MASS

AND SEVERE LLQ PAIN

CT SCAN OF THE PELVIS

Gastrointestinal

endometriosis with

rupture

DIAGNOSIS

12-37% of patients with endometriosis

Rectosigmoid colon, appendix, cecum, distal

ileum

Usually serosal, can cause marked reactive

thickening and fibrosis of muscularis propria

GI TRACT ENDOMETRIOTIC IMPLANTS

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

• 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 APPENDAGITIS

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

•PELVIC LIPOSARCOMA

DIAGNOSIS:

95% OF FATTY RETROPERITONEAL TUMORS

SECOND MOST COMMON RETRO- PRT TUMOR

AFTER MALIGNANT FIBROUS HISTIOCYTOMA

SLOW GROWING

12% CALCIFICATIONS

RETROPERITONEAL LIPOSARCOMA

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 WHENLAYING 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

Polypoid adenomyoma with cystic

degeneration

DIAGNOSIS:

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

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

UTERINE AVM

49 F WITH ABNORMAL BLEEDING

ENDOVAGINAL US

MRI

MRI

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

CLEAR CELL ADENOCARCINOMA

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

CANCER CONTROL. 2009 JAN;16(1):46-52NON-ENDOMETRIOID ADENOCARCINOMA OF THE UTERINE CORPUS: A REVIEW OF SELECTED HISTOLOGICAL SUBTYPES

41 F ABNORMAL BLEEDING

ENDOVAGINAL US

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

LIPOLEIOMYOMA

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

• It is rare (<1% of ectopic

pregnancies) and is likely

associated with in vitro

fertilization and a history of

prior curettage

• In a cervical pregnancy, the uterus

may be shaped like an hourglass

or a figure eight as the fetus

expands within the cervix

• Cardiac activity below the

internal os is highly suggestive of

a cervical pregnancy

CERVICAL ECTOPIC

•2%–4% of all

ectopic pregnancies

INTERSTITIAL ECTOPIC PREGNANCY

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

•2% of all pregnancies and is the

most common cause of pregnancy-

related mortality in the first

trimester (9-14%)

RADIOGRAPHICS. 2008 OCT;28(6):1661-71DIAGNOSTIC CLUES TO ECTOPIC PREGNANCY

•Caesarean scar pregnancies

are rare

•estimated to occur in less than

1% of all pregnancies

C SECTION SCAR ECTOPIC

POSITIVE PREGNANCY TEST 34 F 7 IUP

C SECTION SCAR PREGNANCY

THANK YOU.

MSHETTYMD@WOMANS-CLINIC.COM