CHALLENGING CASES: FEMALE PELVIS

Liina Poder, MD, FSRUProfessor of Clinical Radiology, Obstetrics and Gynecology, UCSFLiina.Poder@ucsf.edu

37 year old with incidentally found bladder mass during second trimester ultrasound.

•Benign or malignant?•Biopsy during cystoscopy?

CASE

T2

37 year old with incidentally found bladder mass during second trimester ultrasound. Managed expectantly. 3 weeks post partum.

T2 during pregnancy T2 post partum

Same patient during pregnancy and post partum appearance of left uterosacral ligament.

•Differential Diagnosis?

T2 pregnant T2 post partum

Same patient during second trimester presented with acute left lower quadrant pain. Concern for ovarian torsion.

•Equivocal US but torsion not excluded

Non-contrast MRI revealed striking intra peritoneal hemorrhage. No cause was identified, left hemorrhagic cyst was suspected. Laparoscopic exploration reveled no clear cause biopsies taken of left adnexa revealed decidual reaction.

T2T1 T1

Emerg Radiol. 2017 Oct 6. Uterine artery pseudoaneurysm in the setting of deep endometriosis: an uncommon cause of hemoperitoneum in pregnancy. Feld Z, Rowen T , Callen A , Goldstein R , Poder L

Uterine artery PSA and bleeding secondary to decidual reaction in deep endometriosis in pregnancy

+ gad

TEACHING POINTS:▸ Young reproductive age female think uncommon presentation of common

disease/Recognize Aunt Minnie when you see her

▸ Endometriosis “Many Faces”: endometriomas, deep endometriosis, decidual reaction, polypoid endometriosis

▸ Common location on deep endometriosis: rectovaginal septum and uterosacral ligaments (69.2%), vagina (14.5%), alimentary tract 9.9%), urinary tract (6.4%)

▸ DPE: subperitoneal invasion by endometriotic lesions that exceed 5 mm in depth

▸ Deep endometriosis MRI: “location”, low T2/masslike/spiculated, high signal T2 and T1 foci (endometrial glands), +/- enhancement

▸ Decidual Reaction: hormonal influence during pregnancy, solid nodules strikingly similar to uterine decidua on T2, high ADC/low diffusion

MRI Imaging in Deep Pelvic Endometriosis: A Pictorial Essay Antônio Coutinho et al, RadioGraphics Vol. 31, No. 2: 549-567

Morisawa at al, J Comput Assist Tomogr 2014;38: 879–884)

Published in: "MR Imaging in Deep Pelvic Endometriosis: A Pictorial Essay"Antônio Coutinho RadioGraphics Vol. 31, No. 2: 549-567Copyright RSNA, 2011

Rectovaginal pouch

Rectovaginal septum

Vesicovaginal septum

Prevesical space

COMPARTMENTAL ANATOMY:Vesicouterine pouch

T2

T2

T2

Hydronephrosis due to DPE

Reproductive age female presented with rectal bleeding.

COMPANION CASE

Cervical versus Rectal Cancer?

T1

+ GAD

T2

▸ Rare variant of benign endometriosis

▸ Imaging: solid appearing + flow (may not have obvious blood products characteristic to endometriomas)

▸ Pathology: more stromal elements, resembles proliferative or inactive endometrial stroma

▸ Surgery/Colonoscopy: polypoid masses Polypoid Endometriosis

POLYPOID ENDOMETRIOSIS

A Clinicopathologic Analysis of 24 Cases and a Review of the LiteratureRobin L. Parker, MD,* Farnaz Dadmanesh, MD,† Robert H. Young, MD,‡ and Philip B. Clement, MD§

30 year old with incidental finding on pelvic ultrasound for “pelvic pain”

SAM 1

T2 T1 + Gad

T2

30 year old with incidental finding on pelvic ultrasound for “pelvic pain”. Based on given

information what is the most likely diagnosis?

A. Bladder leiomyomaB. ParaganglinomaC. NeurofibromaD. Endometriosis

Published in: "MR Imaging in Deep Pelvic Endometriosis: A Pictorial Essay"Antônio CoutinhoRadioGraphics Vol. 31, No. 2: 549-567Copyright RSNA, 2011

SAM 1

30 year old 24 weeks pregnant with superficial right abdominal pain worse

during last weeks of pregnancyWhat is the most likely diagnosis?

SAM 2

out of phase

in phase

T2

A. Rectus intramuscular hematomaB. SchwannomaC. NeurofibromaD. Decidual reaction in endometriotic

implantPoder L, Coakley FV, Rabban JT, Goldstein RB, Aziz S, Chen LM. Decidualized endometrioma during

pregnancy: recognizing an imaging mimic of ovarian malignancy. J Comput Assist Tomogr. 2008 Jul-Aug;32(4):555-8.

Morisawa at al, J Comput Assist Tomogr 2014;38: 879–884)

30 year old 24 weeks pregnant with superficial right abdominal pain worse during last weeks of

pregnancyWhat is the most likely diagnosis?

CASE 229 year old with acute right lower quadrant pain, 23 weeks pregnant with mono-di twins.

4x5.7x4.1 cm 4x2.7x1.9 cm

US could not see appendix. Clinically unclear appendicitis vs ovarian torsion. Mild white count, nausea. Joint case with general surgery and gynecology.Urgent laparoscopy surgery: nl appendix, enlarged rt ovary, purple streaked and edematous, twisted 180 degrees around pedicle. Untwisted with return of normal color.

CASE

rt ovary

rt ovary

left ovary

CASE 2 COMPANION

TEACHING POINTS:▸ Ovarian torsion in pregnancy: 20% occurs in pregnancy (first/

second trimester - ligamentous laxity and physiologic stimulated ovaries/CL/dermoid cyst), > 4- 5 cm, rt > lt

▸ Ovarian torsion: Morphology/asymmetry (edematous storma/follicles pushed to the periphery trumps doppler, about 60% with normal doppler), twisted vascular pedicle harder to find during pregnancy

▸ Any adnexal mass in pregnancy: >6 cm high likelihood of developing torsion during first or second trimester

▸ If US equivocal: MRI non-contrast (ACR "green light" throughout pregnancy if indicated 1.5-3T)

Pearls and Pitfalls in Diagnosis of Ovarian Torsion , Hannah C. Chang et al Radiographics September-October 2008 28:1355-1368

COMPANION CASE39 year old at 23 week anatomy scan with incidental ? right adnexal mass on US (nontender).

T2

T2

Massive ovarian edema: managed expectantly, resolved post partum

rt ovary

left ovary

rt ovary

T1

TEACHING POINTS MOE:

▸ Massive Ovarian Edema: Unilateral Subacute/chronic partial ovarian torsion described during pregnancy (flow present but ovary can be very swollen, teardrop appearance on MRI), non-tender

▸ T1 hemorrhage (more likely torsion) vs no T1 hemorrhage (MOE)

▸ +Twisted vascular pedicle (true torsion)

▸ MOE adjacent compression of uterus/lymphatic obstruction (rare but in differential tumor infiltration)

▸ Expectant management favored, consult experienced ob/gyn Coackley et al, J Comput Assist Tomogr. 2010 Nov-Dec;34(6):865-7

32 year old (not pregnant) with chronic abdominal pain for 3 month, low grade fever. Outside ultrasound with

rt ovarian vascular mass and ? duplicated uterus.

ANOTHER CASE 2 COMPANION

left ovary

rt ovary

inflamed appendix

inflamed appendix

rt ovary

inflamed appendix

terminal ileum

T2

T2T2

T1 post

TEACHING POINTS MOE:

▸ Massive Ovarian Edema: Out of proportion enlarged ovary, no pain and presence of flow think MOE due to other rare causes rather than torsion

▸ In this case massive ovarian edema due to subacute appendicitis

▸ MRI can be helpful modality to complement US findings in pregnant or non pregnant patient

Emerg Radiol. 2017 Apr;24(2):215-218.Massive ovarian edema, due to adjacent appendicitis.Callen et al

37 year old at 23 weeks presented with acute right lower quadrant pain. Right ovary 6x 2.6 x6.3 cm, tender and no

doppler flow.

CASE

37 year old at 23 weeks presented with acute right lower quadrant pain. Right ovary 6x 2.6 x6.3 cm, tender and no doppler flow. MRI shows edematous ovary with internal hemorrhage with twisted vascular pedicle.

T1

T2 T2

rt ovary rt ovary

rt ovary

lt ovary

33year old with acute right abdominal pain, 14w 3 days

pregnant. Pelvic and abdominal US neg acute findings.

EXAMPLES WHEN MRI IMPORTANT ADJUNCT TO US:

twisted vascular pedicle

dermoid cyst fibroma

swollen ovary rt

lt ov

36 year old with acute RLQ pain, nausea and vomiting. US with

edematous ovary but unclear if rt adnexal mass versus uterine/BL in

origin.

T2

T2

28weeks pregnant with RLQ pain and fever. Dif: torsed ovary, TOA, ruptured appy. MRI shows degenerating leiomyoma with bridging vessel sign. lt ovrt ov

T2

T2

20weeks pregnant left pelvic mass: ?origin

FIRST TRIMESTER RT ADNEXAL MASS: FIBROMA (ON IMAGING SIMILAR TO

FIBROID)

lt ovaryrt adnexa

T2 T2

diffusion ADC

41 year old woman, with incidental adnexal findings during 10 w ultrasound

Benign versus malignant?

What is the next step?

T2

T2

T1

41 year old woman, with incidental adnexal findings during 10 w ultrasound

Bilateral solid and cystic masses/thick septations/solid

components/stained glass appearance on T1/T2

Bilateral borderline serous tumor on path

26 year old woman, with incidental adnexal findings during 10 w ultrasound

T2

T2T2 Diffusion

OPTIMAL TIME FOR NON EMERGENT SURGERY DURING PREGNANCY▸ Second trimester 16-20 w, organogenesis is complete, minimizing

the risk of drug induced teratogenesis

▸ The hormonal function of the corpus luteum replaced by the placenta, reduction in progesterone secretion from oophorectomy or cystectomy does not affect progesterone concentration

▸ Almost all functional cysts will have resolved by this time

▸ The risk of pregnancy loss related to second trimester surgery is low

▸ Spontaneous pregnancy losses due to intrinsic fetal abnormalities are likely to have already occurred and will not be erroneously attributed to the surgery

Hoover K1, Jenkins TR, Evaluation and management of adnexal mass in pregnancy.Am J Obstet Gynecol. 2011 Aug;205(2):97-102

MRI IN PREGNANCY PRACTICAL APPROACH

Placental/Uterine Abnormalities

Acute Abdominal/Pelvic Pain

Incidental Adnexal masses

Accreta/Increta/Percreta

Adnexal: Ovarian Torsion, Massive Ovarian edema

Benign:Theca Lutein cysts, Endometriosis,

Fibroids

Subchorionic bleed, Abruption Placentae

GI: Appendicitis, SBO, IBD, Cholecystitis,

Pancreatitis Decidual reaction

Degenerating fibroids GU: Stones, Infection Malignant vs B9

CASE

24 year old female presented to ED with chronic intermittent RLQ pain, R/O appy versus ovarian torsion

CT scan ordered.

LO

?RO

HU 25

CT read:- Neg for AppyLt ovary normal

9 cm cystic structure (25 HU) in the pelvis, ? ovarian rec US to

further evaluate

LO

RO

Very edematous ovary can mimic fluid or cyst, recommend urgent ultrasound (don’t wait!)

US: edematous rt ovary up to 9.5 cm with

peripheralization of follicles and twisted

vascular pedicle, + flow. Most likely intermittent

torsion.

Surgery: Torsed rt ovary180, untwisted.

Subsequent intermittent torsions x3. Patient had

oopexy and ovarian wedge resection.

CASE

17 year old with acute right pelvic pain, + N/V, fever, RO ruptured cyst, pain over transplanted kidney.

17 year old with acute right pelvic pain, +N/V, fever, RO ruptured cyst, pain over transplanted kidney.

17 year old with acute right pelvic pain, +N/V, fever, RO ruptured cyst, pain over transplanted kidney.

T2

T2

T2

Ruptured ovarian cyst + UTI and Pyelo

Young woman with incidental pelvic mass. Query endometrioma?

CASE

Path: Epidermoid cyst

Ovaries seen separately unlikely adnexal pathology.

GI/GU/Neuronal etiology in pelvis

T2

T1

UNICORN?

“A horse who bumped into an ice cream cone”