Extraovarian PELVIC PATHOLOGY: DIFFERENTIAL ... - smri.org.mx endometriosis with rupture DIAGNOSIS 12-37%

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  • 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 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

  • 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):46-52 NON-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