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.