Pitfalls: Female Pelvis, Part 2

Introduction and Learning Objectives

My second talk this afternoon, I'm going to focus on some pitfalls in imaging the non-pregnant patient.

My learning objectives for this talk are to review ultrasound, CT and MR findings and various disorders of the female pelvis in the non-pregnant patient.

And I'll be discussing abnormalities of both the uterus and adnexa.

And throughout the talk I'll be demonstrating the complementary roles of these different imaging methods in evaluation of these disorders.

And I'll be giving you some tips for making a more specific diagnosis, reviewing some pitfalls, and how to avoid them.

I'll be discussing how you can identify normal versus abnormal, which sometimes can be a little bit tricky.

And throughout the talk, I will be showing you the added value of multiplanar imaging, which I think can be really helpful, particularly in CT evaluation of the female pelvis.

Ultrasound Assessment of the Endometrium

I'd like to start with ultrasound assessment of the endometrium.

And ultrasound is of course the primary modality that we use to evaluate the endometrium, and we want to measure this as the maximal AP thickness and the long axis on a transvaginal scan.

This is the so-called double layer thickness.

Generally, the endometrium should be homogeneous and echo texture unless we're in this particular phase of the menstrual cycle, which is the peri ovulatory phase where we see this normal trilaminar appearance of the endometrium.

And it becomes much more difficult to evaluate for endometrial pathology when we try to evaluate patients in the secretory phase, when the endometrium is at it's thickest.

So really it's best if we're assessing a patient with abnormal vaginal bleeding to assess her when the endometrium is at its thinnest in the early proliferative phase of the menstrual cycle.

Now, unless we're in the proliferative phase, the endometrium should be homogeneous.

There should be no focal abnormalities.

And you should see a regular, well-defined endo myometrial interface.

You really need to assess that interface.

And I'll show you some examples of where when you lose that interface, there could be very significant pathology.

And you also wanna make sure that you visualize the endometrium in its entirety.

And if you can't, then you may need to recommend additional evaluation.

Now, we know that it is very important to get an accurate measurement of the endometrium because a thin endometrium has a very high negative predictive value for the presence of endometrial cancer.

And there have been many, many papers now in the literature which have reviewed the data in this regard.

And if you look at the different society recommendations as to what we should be using as the upper limits of normal for the endometrium in a postmenopausal patient who presents with vaginal bleeding, you'll see it differs slightly between the SRU where they advocate five millimeters as the upper threshold of normal.

Our OB GYN colleagues at acog, they actually advocate using less than or equal to four millimeters.

I was on the a CR appropriateness criteria panel a couple of years ago where we reviewed this topic and we acknowledged that either one of these threshold values is probably reasonable, but in any event, if the patient, even if she has a thin endometrium, she's postmenopausal and she has persistent vaginal bleeding, or if she has high risk factors for endometrial cancer, she probably should undergo further evaluation.

Pitfalls in Measuring Endometrial Thickness

Now, one pitfall that you wanna avoid is this.

When you see fluid within the endometrial cavity, you do not want to measure the endometrial thickness like this.

That is incorrect.

What you wanna do is measure each individual wall of the endometrium, sum them up, and then that gives you the double layer thickness.

And Dr. Goldstein, who works with me at NYU in the GYN department, he actually showed a number of years ago now that if you see just a small amount of simple fluid in the endometrial cavity, even in a postmenopausal woman, as long as the endometrium is normal thickness and you do not see any focal abnormalities, it's probably within normal limits.

She may just have some element of cervical stenosis, but again, if she has abnormal bleeding that persists, she may need further evaluation.

Non-Visualization or Incomplete Visualization of the Endometrium

Now, as I mentioned, when you're assessing the endometrium in somebody with abnormal bleeding, you really do may need to make sure that you visualize it in its entirety.

And non visualization or incomplete visualization of the endometrium may be because of the orientation of the uterus.

Sometimes we have an axial uterus where the ultrasound beam is parallel to the long axis of the uterus, and it's very difficult to get a good look at the endometrium.

This is another scenario where a transabdominal scan actually may give you a better perspective on the endometrium.

You may have adenomyosis, you may have uterine fibroids, and all of these things can impede our assessment of the endometrium.

But if you cannot see it or only see it partially, that study has to be considered non-diagnostic for the presence of endometrial pathology.

Now, these authors looked at the management of postmenopausal women with vaginal bleeding when the endometrium could not be visualized.

And they saw this in their cohort of 174 patients, 4% of the time of their total cohort of patients in this study, all of these patients in whom they could not see the endometrium went on to further assessment with biopsy or DNC.

And actually 15% of these women ended up having endometrial cancer.

So, if you are not seeing the endometrium, don't try to sort of guesstimate it.

Don't say, I think I see it.

You kind of start making up measurements, putting calipers on something, you really have to be sure, because otherwise you could miss significant pathology.

Use of Doppler in Endometrial Assessment

Now, I think doppler can be very helpful here.

So this is a woman who presents with vaginal bleeding, and you see the endometrium here.

Note how the endo myometrial interface is pretty well delineated and defined here.

However, posteriorly, we lose it and it appears to be disrupted.

And so you really do have to worry that there could be some perhaps infiltrating process here, involving the endometrium extending into the myometrium.

If you put on doppler, you see that there is this abnormal vascular pattern with all this disorganized vascularity, we basically felt that this was highly likely to represent an infiltrating endometrial cancer, which was ultimately proven biopsy.

Sonohysterography for Better Visualization

Now, if you don't see the endometrium and you're not sure, a couple of other things you can do, you can do sonohysterography.

I think it's a very good application for this technique when you're trying to better visualize an endometrium.

It can also be helpful in terms of differentiating a diffuse endometrial process from a focal one.

So this woman on tamoxifen has this thickened endometrium with these small areas of cystic change.

I don't know, is this hyperplasia?

When you put in the saline, you see that this actually just represents a large endometrial polyp, and patients with focal versus diffuse endometrial abnormalities are going to be managed somewhat differently.

Now, maybe the woman cannot undergo a sono histogram, and about 10% of them it is not feasible because if you can't advance the catheter and you can't cannulate the cervix, then you're not going to be able to instill the saline or you're not going to be able to do the study.

Role of MR in Endometrial Evaluation

I think MR can really be a great problem solver in this particular case as well.

We see that because of the excellent soft tissue contrast resolution with mr, we get a great depiction of the zonal anatomy and architecture of the uterus as we see in this normal patient here.

So this was a 62-year-old woman with abnormal vaginal bleeding.

She had an ultrasound, she has this thickened appearing endometrium.

It looks like it's heterogeneous in echo texture.

And she was actually referred for an MR here.

And when we did this, we saw that the problem here was just this very large, somewhat typical appearing submucosal fibroid that we could make a definitive diagnosis.

The rest of the endometrium appeared to be normal.

On the other hand, this woman was referred again, postmenopausal with abnormal bleeding.

She had actually already undergone a negative endometrial biopsy.

Remember that with endometrial biopsy, there's going to be potential for sampling error, particularly if you're dealing with a focal abnormality.

So an ultrasound, her endometrium was thickened.

Again, it was heterogeneous and echo texture.

A sono histogram was attempted.

What was not successful, she was referred for the mr.

She does have some fibroids, but note how she also has this mass in the endometrial cavity, which is sort of intermediate signal intensity.

You certainly cannot call that a fibroid.

And this was evaluated at hysteroscopy and this was a poly point endometrial cancer.

CT Evaluation of the Endometrium

Now, we don't use CT primarily to evaluate for an endometrial abnormality, but we see the endometrium in every patient, female patient who has a uterus who might undergo a CT scan for some other indication.

And, we have to look at it and we have to assess it.

Do we think it's normal or do we think it's abnormal?

And many times what you'll see in this patient, for instance, has an verted uterus, and you're looking at this endometrial cavity and you're asking yourself, is this thickened?

Is there fluid in there?

I'm not sure.

Is this normal or abnormal?

And I think that this is a really great indication for looking at your sagittal reformats.

And I do this all the time if I suspect or that there could be a problem with the endometrium or I'm not sure.

And that's because in the sagittal plane here, we sort of get an image that simulates the transvaginal ultrasound image that we're more used to looking at when we assess an endometrium.

And here we see that when we do that, it's entirely normal.

Well, what about this, this woman was being scanned for a different reason, not related to her uterus.

And I will tell you that initially a very experienced CT reader called this a fluid-filled, distended endometrial cavity based on this axial image.

However, if you go over and you look at your reformat, what you can see is that the endometrium here is actually entirely normal.

And what this was, was just a low attenuation, degenerating, intramural fibroid.

So again, I really encourage you to use those sagittals.

Now, we put together a pictorial review a couple years ago now in Radiographics where we kind of describe the variable patterns of uterine contrast enhancement that you might see at ct.

And you have to be aware of these different enhancement patterns, which are normal, which are shown in the schematic.

And I'll just show you some examples.

So here's a patient, who's premenopausal menstruating.

And you see this thin band of sub endometrial enhancement as depicted here in this image.

This is felt to correspond to the basal layer of the endometrium.

Again, you don't wanna misinterpret this as an abnormal endometrium.

Sometimes you'll see a somewhat thicker band of sub endometrial enhancement.

As we see here, this corresponds likely to the inner myometrium or the junctional zone.

Sometimes you'll see both an inner band of enhancement as well as an outer band giving you almost sort of like a target appearance.

Here.

Again, this is normal.

And then oftentimes you'll see a more sort of diffuse pattern of enhancement.

And the enhancement pattern will vary depending upon the age of the patient, her menstrual status, the timing of the imaging with respect to the contrast bolus.

But again, in an asymptomatic patient who you just happen to observe these findings, you should not be misinterpreting these as abnormal.

The other thing to be aware is that the cervix can also exhibit a zonal pattern of contrast enhancement.

And oftentimes what you'll see, this is this submucosal inner band of enhancement, outside of which we use, you will see the less enhancing stroma here, and then also sometimes an outer band of enhancement.

You should not consider this to be abnormal.

I've seen people call the Citis, for instance.

Again, this is just a normal pattern.

The other thing is that which I think can be confusing many times is this where remember that there is a overall delayed enhancement of the cervix relative to the myometrium.

It has to do in part related to the alternate blood supply of the myometrium, the cervix, as well as the fact that you do have this large fibrous stromal component of the cervix, which leads to this delayed enhancement.

You do not want to mistake this for cervical mass.

And we can see the same phenomenon at dynamic contrast enhanced MRI, where we see this delayed cervical enhancement here.

Once again, I think that the sagittal reformance, it can be very confusing on the axials, again, depending upon how the uterus is oriented and how you happen to cut across it in the axial plane.

So on the sagittal, if this is normal, what you expect to see is that there's a very sharp, linear, sort of geographic demarcation between the normally enhancing myometrium and the delayed enhancement of the cervix.

Note also how the endometrial cavity, you can follow this uninterrupted into the endocervical canal.

There is no fluid or distension of the endometrial cavity.

On the other hand, in this patient with a cervical cancer, we can see this looks very different.

You can see that there's a bulging contour of the cervix here.

The interface with the myometrium is very irregular because this is basically an invasive cancer.

And you can see that the endometrial cavity is obstructed, so it is distended and fluid filled.

Again, with all of these transvaginal ultrasound still does serve as the gold standard.

So certainly if you have any question or doubt, or if the patient's having symptoms, you should follow up the CT with an ultrasound.

But I think if you can recognize these features, many times, a follow-up ultrasound may not be necessary.

Disorders of the Uterus: Fibroids

Now, moving on to some disorders of the uterus.

I first wanna talk about fibroids.

And these are very, very common.

Usually they don't give us any sort of trouble here.

But there's a couple of different presentations I think, which can be somewhat problematic.

And one of them is the prolapsing or so-called aborting fibroid.

And what this is, is that you have a submucosal fibroid, which is on a long stalk or pedicle, which is oftentimes very vascular.

And what can happen is, it can actually prolapse down into the cervix.

It can splay the cervix here, it can also prolapse into the vaginal canal.

And I'm just gonna show you this C clip here.

And if you haven't seen one of these before, it can be kind of you sort of like, what's going on here?

You may not recognize what's happening if you think this is what's happening back the transvaginal probe out a little bit.

You can see the edge of this mass here.

And many times these patients present in the emergency setting with very excessive, almost torrential vaginal bleeding if they're actively passing or trying to pass this fibroid that can impede the gynecologist from doing an examination.

And so, when you see this, it's really almost sort of a classic mini sort of appearance.

And you can tell them, this woman is prolapsing a fibroid here?

I do wanna caution you though that just recently, in fact in our own practice, we saw an a poly point, a large poly point endometrial cancer presenting in this fashion.

So there are other endometrial masses that can do this, but by far and away fibroids are the most common.

The other thing that you wanna do when you see this is, get a sense of how much intra myometrial extension, if any, there is of this stalk or fibroid into the myometrium.

And this is something our gynecologists ask us, because typically if there is no extension as we see here in this other prolapsing fibroid, then they can resect this vaginally, through a hysteroscopic resection.

On the other hand, if there's more extensive myometrial involvement, then that's going to require an open procedure.

Mimics of Fibroids: Leiomyosarcoma

Now what about this case?

So this woman was being scammed because she had sort of abdominal pelvic pain and her uterus looks like this.

This was read as an enlarged fibroid uterus.

And so you can kind of look at those images, kind of ask yourself, how would I read that case?

So she was referred for ultrasound, and I'm showing you the trans-abdominal images.

And this was also read as sort of a large dominant fibroid.

So this woman was actually referred to our interventional radiology service for a uterine artery embolization of this large fibroid.

And our interventionalists actually require an MR before they will do these procedures because they like to make sure, is this patient a good candidate for this procedure?

And this is what we see.

When this woman had this MRI, we see this very large dominant uterine mass.

You can see it does not have the typical lows T two signal of a fibroid.

It's got some areas of cystic change or degeneration, non enhancing necrotic areas post gato.

The other feature I want you to note, look at how irregular the margins of this are here.

It has sort of an infiltrative appearance.

In fact, it looks like it's infiltrating into the ventral abdominal wall.

Fibroids should be well encapsulated.

It's not uncommon that they can have areas of degeneration, of necrosis, but they should not have an infiltrated margin.

And this was showed a lot of restriction on the diffusion weighted image.

The other thing that was important here was that this was a postmenopausal patient who was complaining of a rapidly growing mass.

And so what are we dealing with here?

Does anyone wanna shout it out?

Right.

So this is a OMI sarcoma.

This is not a benign fibroid.

This is a OMI sarcoma.

And so this was recognized on the mr.

She had surgery, she had chemotherapy.

Unfortunately she came back six months later with multiple large pulmonary metastases and she's got peritoneal disease as well.

So, this is something that we struggle with in our practice sometimes, everybody sort of encounters these funny looking fibroids and the question is, do I have to worry about this or not?

There's been a couple of papers both in the ultrasound and MR Literature that have addressed this.

Unfortunately, there is a lot of overlap.

Many times the clinical picture is most important.

Again, if you have a post-menopausal woman with a rapidly enlarging mass.

But I think if on mr.

For instance, if you see a large dominant mass of heterogeneous sort of intermediate to high signal intensity on T two 80 images, areas of necrosis, particularly areas of hemorrhage, but look at those margins and see whether or not this looks like it's infiltrated or well encapsulated.

And I think there's more work to be done on the role of diffusion weighted imaging in terms of differentiating the benign from the malignant.

This 30 5-year-old woman comes in with a large pelvic mass that we saw an ultrasound.

Again, this is just a fibroid or isn't it?

It's a large dominant mass.

It was heterogeneous and echo texture.

It's got areas of cystic change.

I think one of the difficulties with ultrasound when you're dealing with kind of a funny looking mass like this, is it's hard to evaluate those borders and to see whether or not it's well encapsulated or if it's somewhat infiltrated.

So she was referred to GYN onc, they ordered an mr and you can see that again, this does not look typical sort of intermediate T two signal has large areas of T two high signal intensity areas of necrosis on the post gato also has diffusion restriction here on the diffusion weighted images.

But unlike the other case, it does seem to be well encapsulated.

So that made us feel a little bit better.

But clearly this was still a surgical lesion.

And at surgery this was a cellular oma, which is just sort of in atypical type of fibroid, with areas of degeneration.

But it is still a benign entity.

Well what about this?

This 30-year-old was referred after having had an ultrasound.

Again, a limited field of view of ultrasound makes it difficult when you have a large mass like this.

We saw this and we said, my goodness, this is filling the whole abdomen and pelvis here.

We were of course concerned that this could be a sarcoma, other malignant tumor, but once again it's fairly homogeneous, fairly well circumscribed here.

Clearly a surgical lesion.

And at surgery this was just a totally benign fibroid, not even an atypical fibroid.

It's a totally benign fibroid.

Sometimes when you have a degenerating fibroid with large areas of cystic change, it can simulate it at nexel mass.

What you wanna do of course is see, can I identify the ovaries separate from this mass?

I think in this particular case also on the CT you could see the little divot or defect where this large degenerated fibroid was arising from.

But this was mostly cystic in fact, rather than solid.

So somewhat unusual.

Adenomyosis

Now adenomyosis is another entity which sometimes can give us some trouble.

There's variable sensitivity and specificity of ultrasound.

We're gonna look for the classic features of an enlarged gular uterus, heterogeneous echo texture, areas of shadowing intra myometrial cysts.

What you don't wanna do is to fall into the trap of putting calipers around something, calling it a fibroid.

This really is not well defined enough to call this a fibroid and it's likely just a more focal area of adenomyosis, which sometimes we do see.

And it is important to make that distinction because again, it may impact on how the patient is managed.

If it's a fibroid, maybe it can be treated with uterine artery embolization.

If it's adenomyosis, it's probably not going to respond very well to that procedure.

So MR is an excellent problem solver.

Here we have an enlarged uterus with diffuse adenomyosis.

On the other hand here we have a patient with more focal adenomyosis with thickening of the junctional zone and these small T tube right areas corresponding to the ectopic endometrial glands.

Now when you have both fibroids coexisting with adenomyosis, I mean ultrasound is really difficult to make the distinction.

And here you see very nicely on the mr.

Yes, there are some submucosal fibroids, but this posterior process is really more compatible with an adeno myoma.

And our gynecologist in this patient was pre-op for myomectomy.

She was having infertility issues.

They will resect fibroids, but they will not attempt to resect a focal adeno myoma.

So, it was important for them to know the difference.

Now what about this case is this adenomyosis, this woman is in the first trimester of pregnancy.

You can see this little intrauterine gestational sax.

This came in as a rule out appendicitis.

So ultrasound unfortunately was indeterminate, so she went on to mr.

We see this T two hypo intense area here, abutting the junctional zone.

But note how it has again, linear borders kind of geographic in its shape.

We do not see any of those high T two signal areas.

And importantly as you kind of follow this over serial sequences here, this resolves.

And this is just a transient myometrial contraction.

So if you think that's what you're dealing with, again, wait a little while and or look, most of our pelvic MR protocols do have multiple sequences.

So usually by the time you get to the end of the study you can look to see whether or not this is resolving and it's not actually an actual focal structural abnormality.

Well what about this on this CAT scan, this was called a fibroid uterus.

Again, this woman was being scanned for some other reason, but I encourage you to take a good look at this and ask yourself, do I see any focal discrete fibroid here?

Does it look sort of like a globular shape uterus?

I mean does this kind of look more like adenomyosis?

This woman had an MR and this was indeed adenomyosis.

So you know, we're not gonna send a patient to CT to diagnose adenomyosis, but if we see these features and a patient who's being evaluated for some other reason, we can suggest, and actually Dr. Woodfield put together a series of cases on CT where you can see many of the same findings as we see on ultrasound and Mr.

Where you see these little areas of cystic change.

This one is more focal involving the posterior myometrium.

Again, the sagittal reformat is very helpful here.

Distinguishing Adnexal Masses from Uterine Masses

Well what about this solid, somewhat heterogeneous enhancing lobulated mass in the pelvis here?

You know, is this a big fibroid?

And I think one of the things that sometimes we struggle with on CT is when we have a large mass, what is the origin?

And one thing that can be very helpful for you is to look at the vascularity, either arterial supply or venous drainage.

And what we can see is that the venous drainage of this mass here is actually going into a distended and enlarged left gonadal vein, left ovarian vein.

And this is referred to as the ovarian vascular pedicle sign.

So we would not expect to see that drainage pattern in a uterine mass like a fibroid.

So this is going to indicate that this is an adnexal mass.

And at surgery this was a left ovarian distro genoma.

Likewise, in this patient with this very large granulosis cell tumor, again here we can see the venous drainage here in this enlarged distended left gonadal vein, which of course drains into the left renal vein.

Well what about this?

What is the origin of this mass?

So it kind of looks like that big fibroid that I showed a little while ago.

So let's look at some serial images here.

So here's this vein which is draining this large mass and we're gonna follow this, follow it all the way over to here.

Comes up here into the right upper abdomen, crosses over, comes over here.

And actually this ultimately drained into a branch of the SMV.

This was a mesenteric vein, so this is not gonna be an adnexal mass.

And you know it's important because you might say well it needs to come out, it's a surgical lesion.

But it's true that you do wanna try to triage the patient to the appropriate service for the surgery.

If it's an adnexal mass, GYN possibly GY GYN on is gonna see her.

Whereas if it's arising from the mesentery, you know she's gonna be seen by the general surgeons.

And actually this did come out here, it is draining into the SMV and this was a very large mesenteric fibroma.

And actually based on that venous drainage, this diagnosis was considered the leading diagnosis before this patient went to the or.

Now what about this?

Is this solid mass here next to the uterus, an exophytic fibroid or is it an adnexal mass?

She went to ultrasound, they see the mass, it's solid, it's hypo coic, it's shadowing.

Could be a fibroid.

But you have to ask yourself, have I seen both ovaries?

And if I see a mass here and I can't account for both ovaries, then I cannot exclude the possibility of a solid adnexal mass.

And I will tell you that this woman had a couple of different pelvic ultrasounds where this was consistently called epi pedunculated exophytic fibroid.

Well finally somebody said, well gee, I'm not sure I see a normal left ovary.

So she went to mr.

You could see she was postmenopausal.

There's a small atrophic right ovary here, there was no normal left ovary scene.

Here's this mass, kind of looks like a fibroid.

It's T two hypo intense, got some areas of cystic change, it enhances.

But there was no normal left ovary scene.

So this was called a solid left ovarian mass.

And she went to surgery and it was indeed a Brenner tumor arising from the left ovary.

So that's a pitfall you wanna be careful about.

If you're not sure on ultrasound, recommend an mr.

Dermoids and Overlooked Adnexal Masses

Here's another pitfall, 30-year-old who comes in with right pelvic pain.

Her clinician feels a pelvic mass.

You start with ultrasound and this ultrasound was red as normal.

So here we have a right ovary, it's got a corpus lutetium in it here we have a nice normal left ovary, it's got some follicles.

This was red as no pelvic mass identified.

So just take a good look at those images.

Again, she's got right sided pain.

Well patient was still having pain so she got referred actually for an R of the hip.

And what we saw here was that she has a mass now in the right ad nexa, it's dropping out on the T one fat suppressed image.

What is this?

Of course this is a dermoid.

Dermoids are notorious for being overlooked at ultrasound.

I think if you go back and look at the original ultrasound, if you look very carefully you see that there's apparent mass effect on this ovary has kind of a crescentic shape.

And I've seen this a number of times now and this is actually the dermoid right here and because it was largely bulk fat, it was kind of blending in with the rest of the pelvis, the bowel, et cetera.

So when these are solid, mostly in bulk fat they can be very, very tricky and they can be easily overlooked.

Here's a 31-year-old with left pelvic pain.

She has an ovary that looks like this.

This was read as a complex cyst, probably a hemorrhagic cyst in this ovary, but she had persistent pain and so the gynecologist decided to order an MRI and on the MRI, you see there's a much larger mass here measured up to six centimeters.

It's got components that drop out on the T one weighted fat suppressed image.

It's also got components that drop out as you go from the endphase to out of phase confirming that there's both intravac fat as well as bulk fat.

And this was another dermoid.

And I think again in going back and looking at this ultrasound, probably this is it here, and it was just sort of obscured and blending in.

And I think this is another situation where you think you might be looking at dermoid, put a little gentle pressure with the probe, put some pressure with your non scanning hand, move the bowel away, see if you can isolate it.

And sometimes even you might get a better look at it transabdominally rather than transvaginally.

But I encourage you, if you have a patient, someone feels a mess, you are not seeing it on ultrasound, think strongly about the possibility of a dermoid.

Metastatic Disease Mimicking Primary Ovarian Neoplasms

This woman presented to the ER at Bellevue with pelvic pain.

I'm not sure why, but they decided to start with a CAT scan.

And on the CAT scan we see this solid mass here.

This was called as likely a primary ovarian neoplasm, solid heterogeneously enhancing mass.

Whenever you have a newly identified ad nexel mass on any imaging modality, this happens to BCT.

Think about the possibility that it's not primary, but could it be coming from somewhere else on ct?

We can look at the rest of the abdomen and pelvis when we do that in this patient we see this securous carcinoma here of the gastric antrum with the associated gastric outlet obstruction.

And this it's was a berg tumor with metastasis to the ovary.

Our gynecologists get very upset if we tell them that there's a primary ovarian malignancy in a patient and it actually turns out to be a metastasis from somewhere else, either from the stomach, the colon, et cetera.

So if you have the opportunity particularly on CT to make that diagnosis and suggest it, by just carefully looking at the rest of the images, I've seen colon cancers present this way or the colon cancer itself didn't cause the presentation but the adnexal mass did ovarian torsion.

Ovarian Torsion

Very important topic.

Couple of pitfalls here.

You know, this is the diagnosis we don't wanna miss.

We wanna identify this early on in the game so that the ovary can be salvaged at the time of surgery.

We know now from many, many reports in the literature that doppler ultrasound here is faulty and that's because many times the torsion will be early, it'll be partial intermittent, and you may actually see preservation of arterial flow, arterial flow that actually looks relatively normal.

And what you need to do is you need to look at the ovary itself.

You need to look for the gray scale findings.

Is the ovary enlarged?

Does it look malpositioned?

Is it in the wrong place?

Does the ovary look emus?

It's hypo coic.

Is there peripheral displacement of the follicles because of this swollen ovary?

This patient has a hemorrhagic ovarian cyst.

And what you need to do when you have a cystic mass and it's tricky, you need to look beyond the mass and you need to try to find the ovary and ask yourself, does it look normal or abnormal?

Based on this gray scale appearance, despite the flow and given the fact that the patient came in with acute onset of pelvic pain, she was taken to the or this was a tors ovary with a benign hemorrhagic cyst and it was revascularized, she did not lose her ovary.

And this study just showed that in a cohort of patients with torsion that they looked at, 90% of them actually had normal arterial and venous flow at ultrasound.

In fact, you wanna see flow, that's the best situation because that's when you have the opportunity to salvage the ovary.

This is two cases of enlarged emus avascular ovaries that were TAs and unfortunately could not be salvaged.

They were already infarcted a more recently described sign as this, the follicular ring sign.

And you can see this either transabdominally or transvaginally.

And what happens here is that because the ovary is swollen, it becomes more hypoechoic.

So the walls of these peripherally displaced follicles become more hyper coic and kind of stand out as a ring.

It's kind of analogous to the setting of acute hepatitis in the liver and the story sky appearance that we see when the portal triads become more echogenic against the background of the swollen and indemnity liver.

And I think looking for this sign could help you if you're kind of on the fence about whether or not you think there's a torsion.

Here's a dermoid in this ovary in this woman with pain.

This is a very large mass.

Here you again, I'm worried about torsion.

Let me see, can I find the ovary?

You see just a small crescent of ovarian tissue at the edge of this mass when you see this follicle it deed and does demonstrate this follicular ring sign.

We sent her to the OR and this was indeed tors.

But because this dermoid was so large, they ended up just doing an ectomy 41-year-old with acute onset of right pelvic pain.

She has a multiloculated cystic mass here.

And this was sort of located at the midline again despite the cystic mass.

We can see the ovary.

It looks swollen, it looks emus here I think we can see this follicular ring sign.

Look at the flow in this ovary looks normal.

It's not even a high resistance arterial waveform, but this patient exhibited another sign, the whirlpool sign.

And what happens there, and I'm just gonna show this on the C clip, is that the pedicle becomes twisted.

You know it may become twisted around the in fibular pelvic ligament and you can actually see this spiral here.

And you wanna make that observation because again, if you're sort of in a indeterminate situation, if you see that, then that sort of clinches the diagnosis for you.

We don't use ct, to primarily diagnose torsion, but we see many, many cases of patients with pain where something else is suspected.

Diverticulitis, appendicitis, kidney stone, they come in and they do a ct.

And we need to be able to recognize the CT findings of torsion, which pretty much parallel those that we see at ultrasounds.

Or here we've got an infarcted ovary.

It's big, it's heterogeneously enhancing, it's got peripheral follicles.

Here we have, this was done as a rule out appendicitis.

What you have to note is the asymmetric size of these ovaries.

Look at this swollen right ovary compared to the left ovary.

Torsion was called here.

She went to surgery, it was twisted once it was revascularized and they were able to salvage it.

Here's a patient who comes in in 2007.

She's got this dermoid, she was being scanned for another reason.

Now she comes back in 2010 with pain.

We see the dermoid but note how it's in a different orientation right away.

That's a tip off.

That's something is going on here.

Then if you look on the sagittal, you can actually see the ovaries separate from that.

Fatty mass.

Again, it looks swollen.

And then this is actually the tube that I can think you can see much better advantage on the sagittal, which is congested because the whole thing, the ovary and the tube was indeed towards this 40-year-old with acute onset of right lower quadrant pain.

Has a normal right ovary with normal flow.

She had this multiloculated cystic mass, which was actually in the midline pelvis.

We could not see a normal left ovary.

There was no flow in this.

We thought that this was likely something like a epithelial neoplasm with associated torsion.

Gynecology wasn't so convinced that she was having an acute torsion.

They decided to wait for GYN oncology before they did the surgery here.

And in the meantime they got this CT scan for staging.

Here you see this large multiloculated mass and then you see this amorphous soft tissue density next to it.

Well what's going on here?

I'm gonna show you a sequence of images here.

Look at this left adnexal region and you're gonna begin to see this spiral appearance here and we'll just kind of go back and forth.

And this is sort of the CT equivalent of that roll pool sign.

And this is probably the congested tube here.

And she did go to surgery and this was confirmed to be a mucin cystadenoma.

The left ovary was torsed and it was infarcted.

This 40-year-old is status post total abdominal hysterectomy.

Now with pelvic pain.

This abnormality was observed in the pelvis.

This was actually called an abscess, possibly infected hematoma.

This underwent percutaneous drainage.

They got out some serosanguinous material, she did well for a few days.

The drain fell out.

She had recurrent symptoms, they repeated the ct.

We looked at the CT and now somebody said, Hmm, maybe we should do an ultrasound on this patient.

We looked at the ultrasound and here what you have is actually the ovary.

It is swollen, it's got some hemorrhagic areas within it, absolutely no flow.

And she went to surgery and this was an infarcted ovary.

So one point that I wanna make again is that if you see an adnexal mass in a patient with pelvic pain, you must think about the possibility of torsion.

Now this group looked at the prevalence of abnormal CT findings in patients with proven ovarian torsion and this is actually reassuring.

They had a third of their patients with torsion who had a ct.

All of them had an enlarged ovary, a cyst, or an adnexal mass.

If the CT showed a well visualized normal ovary, they did not have, see any cases of torsion.

So again, it emphasizes the point that if the ovary looks abnormal at CT or you cannot see a normal ovary, you must follow up with an emergent ultrasound.

Ruptured Hemorrhagic Ovarian Cysts

Ruptured hemorrhagic ovarian cysts.

I talked about this a little bit earlier here.

We have a big clot in the adnexa here.

Sometimes you can identify the ovary.

Again, I just wanna caution you make sure the patient's beta is negative and make sure that this is not a ruptured ectopic.

Many times we'll see this at ct, we see the sentinel clot in the pelvis even though the cyst is ruptured, we can still see it here with the enhancing wall.

And this patient actually also demonstrates some PU puddling or active extravasation of contrast in our place.

We looked at a series of women who presented in the ER and had both CT and ultrasound, CT first and then ultrasound within 48 hours.

And we had a number of cases of hemorrhagic variances, all of which were accurately called on the ct.

So really ultrasound was not necessary in that instance.

And also we had 10 cases of a normal ct, all of which were followed by normal ultrasound.

So again, probably unlikely that you're gonna be dealing with a torsion if you can identify a normal ovary.

Ruptured Dermoid and Other Causes of Pelvic Fluid

This woman comes in with abdominal pain.

She's got a large amount of fluid here.

This dermoid was identified but it wasn't clear what was causing the fluid.

You know, they were thinking could this be carcinomatosis from an occult cancer?

Could this be tuberculous peritonitis?

And what you have to recognize is that there's a little fat droplet outside of this dermoid.

There's also some fat along the peritoneal surface.

And this of course is a ruptured dermoids.

If you see a dermoid, lots of fluid, think about the possibility of dermoid rupture.

This 28-year-old woman comes in with abdominal pain and bloating.

She's got a large amount of ascites here.

And aside from a fibroid uterus, it looked pretty normal.

So again, we were going down the pathway, is this carcinomatosis infection?

You know, what's causing this fluid?

Actually it was sampled, it was serosanguinous.

She ended up going to laparoscopy.

This was endometriosis.

And what happens is that it's rare, but you, we've seen a couple of cases like this where you get little endometrioid implants studding the peritoneal surface and these patients can actually present with large volume ascites.

Endometriosis

Hers and I, and I just use this to introduce a couple of cases of endometriosis because I think, they can be sometimes, we don't think about it.

And we should.

And so here's a woman, she's already had an appendectomy.

She's got this soft tissue mass at the base of the secum.

This was read as likely a SE L mass or cancer.

She actually went to a he colectomy.

This was an endometrioid implant.

Here's a woman with this mass in the abdominal wall.

Her history is notable for having had a prior ectopic.

And this turns out to be an implant at the trocar site.

And she was sent for a CT because they were worried about a hernia there and actually weren't even thinking about an endometrioid implant.

Another patient with a possible peri umbilical hernia.

And we didn't see a hernia but we saw this enhancing soft tissue nodule.

And so we said, the umbilicus is sort of a physiologic scar and you can get endometrioid implants there.

And so we suggested that it was biopsied and it was endometriosis.

She did not have a history of pelvic endometriosis, which is oftentimes the case in these patients with these abdominal wall implants.

34-year-old with fever and pelvic pain.

She has this mass, it's hard to say on ct it looks like a complex cyst.

She went to ultrasound, very typical appearance of an endometrioma homogeneous low level echoes.

Wasn't clear what's causing her fever.

She was in house on antibiotics.

Finally, they decided to drain this.

They got out 700 ccs, a pus at surgery.

This was an infected endometrioma.

Hydrosalpinx and Mimics

So these can become super infected Hydros pings.

Usually we recognize this by its tubular shape.

Beware that sometimes adnexal masses including cancers such as this mucinous as adenoma, can also look somewhat tubular on ct.

We can recognize the tubular nature many times, but sometimes we can't.

This is a patient with a chronic tub, ovarian abscess.

Very hard to differentiate from a multiloculated cystic mass.

But when we look on the sagittal reform now we can appreciate the tubular nature of this are all tubular fluid filled structures in the pelvis, the fallopian tube.

Well know here's a tubular structure.

It really doesn't have any of the features of fall fallopian tube.

And when you follow it back, it hooks up with the cecum.

This of course is a mucus seal of the appendix patients sent for transvaginal ultrasound to rule out PID.

The ovaries look normal.

We see this tubular structure here.

Again, it has more of the features of bowel rather than a tube.

On the ultrasound we suggested that this was acute appendicitis surgery as for a confirmatory ct.

And here's the acute appendicitis right here.

So we do occasionally pick up acute appendicitis when patients are being sent for pelvic ultrasound for PID.

Here's the patient where the ultrasound was indeterminate.

And CT was very helpful because we saw a normal appendix and here in fact was the dilated fallopian tube.

I think this is another situation which can be very difficult where you have a young woman with peritonitis.

She's got thickening of the peritoneal reflection, some complex fluid.

Is this PID or is it a perforated appendix?

We couldn't really see the appendix.

She's got something cystic in the adnexa.

I think ultrasound can be very helpful here.

When we did that, the ovary looked normal with the exception of corpus lium.

But here is the appendix and in fact the wall was disrupted and this was proven to be a perforated appendicitis.

This is in your handout.

This group looked at this and they found that it's more likely to be a perforated appendicitis if you see seql thickening or if you see air in the abscess because it's very unusual for TOA to be associated with air.

Miscellaneous Cases

And in my last minute, I just wanna show you a couple of cases here, to finish up.

This patient has pelvic pain and fever.

She had this large cystic mass in the pelvis.

It wasn't quite clear what's going on here.

She was sent to ultrasound person who did the ultrasound, saw the cystic mass.

It had this echogenic component.

Looked like there was some shadowing.

You might think.

Is this a dermoid?

Unfortunately they did not correlate the ultrasound with the ct.

She went to the, OR thinking that this was a dermoid.

This is actually what they retrieved.

This of course is a gai oma and this was a retained surgical sponge and that's what it looked like on the ultrasound.

She had had the surgery in an outside country 10 years prior and I guess they don't put those radio peg markers.

And so that's why it wasn't recognized.

Here is a case that we had from Bellevue where this is a gazi oma where now you do see that radio peg marker.

It's always helpful to know the history.

And the last thing I wanna show you is that this patient has a fever.

She's two weeks out from A-T-H-B-S-O.

You know, is this sort of collection of gas here in an abscess?

Well, again, it's very helpful to know the history here.

And it turns out that this woman was bleeding at the time of surgery and they put in gel foam.

And these bioabsorbable agents, this was already shown earlier, this morning, such as surgicel and gel foam, they can very much mimic an abscess.

And so if you see that appearance where these sort of tightly clustered bubbles of air, make sure you know, you ask and could this potentially be one of these agents?

Summary

So then in summary, I hopefully I've shown you that ultrasound CT and MRI think really can play very complimentary roles in evaluation of the female pelvis.

I think it's important to become familiar with the spectrum of normal again, adnexal mass and pain.

Rule out torsion.

Be aware of dermoids that can be problematic and tricky.

Always think about endometriosis.

If you have an unusual finding in a young female patient, know the history.

Use those NPR images and I think that you know, many times on ct rather than just sort of knee jerk response, recommend an ultrasound.

Many times we can do better than that and actually make a more definitive diagnosis and obviate the need for additional imaging.

With that, I thank you very much for your attention.