An unusual cystic presentation of pelvic skeletal Ewing sarcoma: a case series

Ewing sarcoma (ES) is the second most common primary malignant bone tumour in children and adolescents. About 14.5% of primary malignancies develop in pelvic bones, where they typically have worse prognoses than extremity or acral sarcomas. It usually presents with aggressive features on radiology scans, but may also present with different radiological characteristics. In this series, we describe rare appearances of pelvic skeletal Ewing sarcoma, with large extraosseous cystic component on imaging, defined by the presence of fluid-filled spaces in the extraosseous tumour lesion, which distinguishes it from the solid nature of conventional ES. We report 3 cases of cystic presentation of ES, with imaging features supporting diagnosis of a primary malignant bone tumour arising from the superior pubic ramus with associated massive intrapelvic solid and cystic mass. CT-guided biopsy provided diagnosis of ES, with large intrapelvic soft tissue and cystic component. These patients underwent neo-adjuvant chemotherapy and proton beam therapy with significant reduction in size of the solid components, while the cystic components remained relatively unchanged. Two patients underwent surgical resection of the tumour (navigated P3 internal hemipelvectomy and hemipelvis P2/P3 resection, respectively), and one patient died while on treatment. In both who underwent surgery, histology showed ES with margins clear and more than 99% of treatment-induced necrosis. To the authors' knowledge, this unusual presentation of pelvic ES is described for the first time in the literature as a case series, with particular reference to atypical extraosseous cystic changes, along with the clinical and radiological characteristics, and their treatment.

Cystic Pelvic Masses in Men: A Presentation of Uncommon Cases and a Literature Review

Unclear cystic masses in the pelvis in male patients are a rare situation and could be of benign or malignant origin. The underlying diseases demand for specific diagnostic and therapeutic approaches. We present a case series of 3 male patients with different clinical symptoms (perineal pain, urinary retention and a large scrotal cyst) related to cystic lesions in the pelvic region. On all patients initial histopathological workup was unclear. All patients underwent surgery with complete resection of the tumor which revealed a broad spectrum of histopathological findings: unusual form of cystic adenocarcinoma of the prostate, malignant transformation of a dysontogenetic cyst, and finally a very rare diagnosis of a malignant tumor of the Cowper gland. This case series and literature review provide clues for a possible diagnostic and therapeutic approach in the case of unclear pelvic cystic masses and could support urologists during the therapy selection in the future.

Endometriosis MR mimickers: T1-hyperintense lesions

Endometriosis is a chronic and disabling gynecological disease that affects women of reproductive age. Magnetic resonance imaging (MRI) is considered the cornerstone radiological technique for both the diagnosis and management of endometriosis. While MRI offers higher sensitivity compared to ultrasonography, it is prone to false-positive results, leading to decreased specificity. False-positive findings can arise from various T1-hyperintense conditions on fat-suppressed T1-weighted images, resembling endometriotic cystic lesions in different anatomical compartments. These conditions include hemorrhage, hyperproteic content, MRI artifacts, feces, or melanin. Such false positives can have significant implications for patient care, ranging from incorrect diagnoses to unnecessary medical or surgical interventions and subsequent follow-up. To address these challenges, this educational review aims to provide radiologists with comprehensive knowledge about MRI criteria, potential pitfalls, and differential diagnoses, ultimately reducing false-positive results related to T1-hyperintense abnormalities.Critical relevance statementMRI has a 10% false-positive rate, leading to misdiagnosis. T1-hyperintense lesions, observed in the three phenotypes of pelvic endometriosis, can also be seen in various other causes, mainly caused by hemorrhages, high protein concentrations, and artifacts.Key points• MRI in endometriosis has a 10% false-positive rate, leading to potential misdiagnosis.• Pelvic endometriosis lesions can exhibit T1-hyperintensity across their three phenotypes.• A definitive diagnosis of a T1-hyperintense endometriotic lesion is crucial for patient management.• Hemorrhages, high protein concentrations, lipids, and artifacts are the main sources of T1-hyperintense mimickers.

Added value of gadolinium-based contrast agents for magnetic resonance evaluation of adnexal torsion in girls

PURPOSE

Ultrasound is the first-line imaging modality to evaluate adnexa in girls with clinical suspicion of torsion. Patients with equivocal ultrasound findings can undergo MRI for better delineation of adnexal pathology. Here, we assess the utility of intravenous contrast in MRI evaluation of adnexal torsion in children.

METHODS

Two pediatric radiologists (R1, R2) retrospectively reviewed 198 pelvic MRI exams in 172 girls (median age 15 years). Each MRI was reviewed twice. The first review included pre-contrast images only. A second review, at least 1 month later, included both pre- and post-contrast images. Readers concluded if findings were suspicious for torsion or not. Readers' findings were compared to each other's and to surgical and MRI reports and clinical course.

RESULTS

198 MRI exams yielded 354 evaluable ovaries. Surgical and pathological reports were available for 47 patients. 11 patients had adnexal torsion. Both readers accurately diagnosed acutely torsed ovaries during pre- and post-contrast reviews (n = 4). However, readers disagreed on torsed paraovarian cysts (n = 4) and chronically/intermittently torsed ovaries (n = 3). In 21 non-torsed ovaries that had lesions, one or both readers concluded that there were pre-contrast features of torsion. In this set with ovarian lesions, contrast helped readers to correctly conclude no torsion (R1 = 8, R2 = 6) more commonly than to incorrectly conclude torsion (1 each), improving post-contrast specificity for each reader.

CONCLUSIONS

Post-contrast sequences did not provide additional benefit in evaluating acutely torsed ovaries but helped in excluding torsion in patients with adnexal lesions. Therefore, contrast administration should be individualized, potentially reserved only for those with abnormal ultrasound or pre-contrast images.

Mimics and Pitfalls of Primary Ovarian Malignancy Imaging

The complex anatomy and similarity of imaging features of various pathologies in the pelvis can make accurate radiology interpretation difficult. While prompt recognition of ovarian cancer remains essential, awareness of processes that mimic ovarian tumors can avoid potential misdiagnosis and unnecessary surgery. This article details the female pelvic anatomy and highlights relevant imaging features that mimic extra-ovarian tumors, to help the radiologists accurately build a differential diagnosis of a lesion occupying the adnexa.

PET/CT Variants and Pitfalls in Gynecological Cancers

The role of hybrid imaging with 2-[18F] flourodeoxyglucose (FDG) positron emission tomography and computed tomography (PET/CT) is continuously evolving and now considered standard practice in evaluation of disease stage, treatment response, recurrent disease and follow-up for numerous primary malignancies. In gynecological malignancies FDG PET/CT plays an important role, not only in the assessment of disease in the pre-and post-therapy setting, but also in radiation therapy (RT) planning by defining the metabolically active gross tumor volume (GTV. The glucose analogue radiotracer, FDG, is by far the most utilized radiotracer in PET/CT and is typically seen with high uptake in malignant cells. The radiotracer FDG has a high sensitivity but low specificity for malignancy, as benign processes with an inflammatory response for example infection, are also FDG-avid. In the evaluation of the female pelvic region an awareness of potential confounding factors in the interpretation of FDG is essential as variations of FDG uptake occur in accordance with the menstrual cycle and the menopausal state. Incidental imaging findings in the female genital can pose differential diagnostic challenges as false-positive and false-negative findings in benign and malignant processes are not uncommon. Gynecological malignancies continue to pose major public health problems with cervical cancer as the fourth most common cancer in women ranking after breast cancer, colorectal cancer and lung cancer. Familiarity with frequently encountered benign and malignant variants and pitfalls in FDG PET/CT in the female pelvic region can aid the reader in differential diagnostic considerations.

Diagnostic clues, pitfalls, and imaging characteristics of '-celes' that arise in abdominal and pelvic structures

'-Celes' is an ancient Greek language suffix that means 'tumor,' 'hernia,' 'swelling,' or 'cavity.' There are many '-celes' in the abdomen and pelvis that may be encountered during routine imaging interpretation, including santorinicele, choledochocele, ureterocele, lymphocele, mucocele, rectocele, cystocele, peritoneocele, varicocele, spermatocele, hydrocele, hematocele, pyocele and syringocele. Most '-celes' are detected incidentally at imaging for other clinical indications, but some deserve more attention due to a range of clinical symptoms or functional disorder that can adversely affect patient quality of life. The objective of this article was to address all of the '-celes' that a general radiologist and abdominal radiologist should know and be able to recognize. Imaging characteristics, diagnostic clues, and pitfalls have been provided to improve diagnostic accuracy and patient outcomes.

Adnexal masses characterized on 3 tesla magnetic resonance imaging - added value of diffusion techniques

Background

To assess different types of adnexal masses as identified by 3T MRI and to discuss the added value of diffusion techniques compared with conventional sequences.

Patients and methods

174 women age between 13 and 87 underwent an MRI examination of the pelvis for a period of three years. Patients were examined in two radiology departments – 135 of them on 3 Tesla MRI Siemens Verio and 39 on 3 Tesla MRI Philips Ingenia. At least one adnexal mass was diagnosed in 98 patients and they are subject to this study. Some of them were reviewed retrospectively. Data from patients’ history, physical examination and laboratory tests were reviewed as well.

Results

124 ovarian masses in 98 females’ group of average age 47.2 years were detected. Following the MRI criteria, 59.2% of the cases were considered benign, 30.6% malignant and 10.2% borderline. Out of all masses 58.1% were classified as cystic, 12.9% as solid and 29% as mixed. Оf histologically proven tumors 74.4% were benign and 25.6% were malignant. All of the malignant tumors had restricted diffusion. 64 out of all patients underwent contrast enhancement. (34 there were a subject of contraindications). 39 (61%) of the masses showed contrast enhancement.

Conclusions

Classifying adnexal masses is essential for the preoperative management of the patients. 3T MRI protocols, in particular diffusion techniques, increase significantly the accuracy of the diagnostic assessment.

Sigmoid cancer mimicking ovarian echotexture on transvaginal ultrasound: Case report with literature review

Ultrasound is a first line imaging modality for the evaluation of female pelvic pain. Pelvic pain constitutes one of the most common reasons for presentation to the emergency department with increasing use of point of care ultrasound. Infrequently, point of care or formal ultrasound evaluation may lead to misdiagnosis of extraovarian disease. This can have serious consequences, especially if an extraovarian malignancy is mistaken for a normal ovary or an ovary with a benign process. We present a case of a 41-year-old female who presented to the emergency department for a chief complaint of pelvic pain and vaginal bleeding. Transvaginal ultrasound demonstrated a left adnexal mass, later characterized as a sigmoid colon cancer on MRI and pathology, simulating ovarian echotexture with peripheral hypoechoic components resembling follicles. This article will review the literature of various cases of extraovarian pathology misidentified as ovarian processes and highlight the importance of considering these extraovarian mimickers to prevent potential morbidity and mortality of a missed diagnosis.

Uterine adenomatoid tumor associated with lymph node lesions: a case report

We report a case of uterine adenomatoid tumor (AT) with regional lymph node involvement in a 49-year-old woman. Magnetic resonance imaging revealed an aggregated cystic mass in the posterior uterine wall with partial protrusion of the tumor outside the uterus, and cystic masses of same characteristics in the bilateral obturator and right common iliac lymph nodes. FDG PET/CT revealed no significant FDG uptake in the uterine and lymph node lesions. Taking possible lymph node metastasis into consideration, hysterectomy and lymph node biopsy were performed and it revealed AT of the uterus and the lymph nodes histopathologically.

Giant abdominal cyst in a young female patient: A case report

•

We should consider the differential diagnoses of an abdominal cyst.

•

In premenopausal women, ovarian cysts are frequent and may grow to considerable size.

•

Some ovarian cysts cause symptoms, such as obstipation, vomiting and malnourishment.

•

US is the primary imaging study for an ovarian cyst.

•

Persistent simple ovarian cysts larger than 10 cm should be considered for surgery.

Introduction

Most abdominal cysts derive from the ovary. The range of differential diagnoses is wide. Unfortunately, imaging studies not always determine its origin.

Presentation of case

The authors present the case of a 20-year-old female patient, admitted to the emergency department due to abdominal pain and distension, whose imaging studies revealed a gigantic abdominal cyst of unknown origin. She underwent an exploratory laparotomy that disclosed an ovarian cyst that was removed by a left adnexectomy. It weighed 10Kg and was 60 cm wide. The pathology report showed a mucinous cyst adenoma.

Discussion

Once a patient present with an abdominal cyst, one should always consider the extensive list of differential diagnoses. In premenopausal women, ovarian cysts are very frequent. Cysts may grow to considerable size. Our patient was symptomatic, malnourished and dehydrated. Neither ultrasonography nor computed tomography were able to define the origin of the cyst. Persistent ovarian cysts larger than 10 cm, particularly if symptomatic, should be considered for surgery.

Conclusion

Progressive abdominal distension in premenopausal women should raise suspicion of an ovarian tumor, such as mucinous cystadenoma. These tumours are benign, but when their size is considerable, complications do arise and their surgical removal may be life threatening.

The Peritoneum: What Nuclear Radiologists Need to Know

The peritoneum is the largest and most complex serous membrane in the human body. The peritoneal membrane is composed of a layer of mesothelium supported by a thin layer of connective tissue. The peritoneum is one continuous sheet, forming two layers and a potential space between them - the peritoneal cavity- which is subdivided into multiple communicating spaces containing small amount of serous fluid that facilitates frictionless movement of mobile intraabdominal viscera. Peritoneum also contributes to fluid exchange mechanism and plays a role in immune response. The peritoneum is subject to many neoplastic and non-neoplastic processes including infections, trauma, developmental and inflammatory processes. Different Nuclear Medicine imaging techniques can be used to diagnose peritoneal diseases, most of these techniques can be customized depending on the clinical scenario and expected findings. Peritoneal scintigraphy can detect abnormal peritoneal communication or compartmentalization. Several nuclear medicine techniques can help characterize intraperitoneal fluid collections and differentiate sterile from infected fluid. PET imaging plays an important role in imaging of different neoplastic and non-neoplastic peritoneal pathologies. Nuclear radiologists need to be familiar with peritoneal anatomy and pathology to interpret peritoneal findings in dedicated peritoneal nuclear medicine imaging studies, as part of more general nuclear medicine scans, or on CT or MRI component of hybrid imaging studies. The purpose of this article is to review the normal peritoneal anatomy, various pathologic processes involving the peritoneum, and different nuclear medicine and hybrid imaging techniques that can help detect, characterize, and follow up peritoneal pathology.

Imaging of Benign Adnexal Disease

This article provides an overview of the imaging evaluation of benign ovarian and adnexal masses in premenopausal and postmenopausal women and lesions discovered during pregnancy. Current imaging techniques are discussed, including pitfalls and differential diagnosis when necessary, as well as management. It also reviews the now well-established American College of Radiology (ACR)/Society of Radiologists in Ultrasound consensus guidelines and covers the more recently introduced Ovarian-Adnexal Reporting and Data System by the ACR and the recently published ADNEx Scoring System.

Imaging in pediatric ovarian tumors

The spectrum of ovarian tumors in the pediatric population differs significantly from that in adults. Germ cell tumors are the predominant class of ovarian tumors in children, whereas epithelial tumors are the most common in adults. Ultrasonography is the modality of choice for the initial evaluation of pediatric ovarian tumors. Determining the diagnosis based on imaging may prove difficult, and combining the imaging findings with the clinical scenario is very helpful in reaching a differential diagnosis during clinical practice. We will discuss the spectrum of ovarian neoplasms in the pediatric population and describe their clinical, pathologic, and imaging characteristics. A few unique entities related to ovarian tumors, such as growing teratoma syndrome, anti-N-methyl-D-aspartate receptor encephalitis, and hereditary ovarian tumor syndromes, are also discussed. In addition, we will review several entities that may mimic ovarian neoplasms as well as their distinct imaging features.

Retroperitoneal cystic masses: magnetic resonance imaging features

The objective of this review is to discuss the clinical and histopathologic features, MRI characteristics, and management options of retroperitoneal cystic masses. Radiologists should be familiar with the MR imaging characteristics of retroperitoneal cystic masses to allow for a refined differential diagnosis, assist with lesion management, and prevent unnecessary invasive procedures.

Αdnexal cystic lymphangiomas in patients with massive leiomyomatous uterus: a not so uncommon finding on pelvic MRI

PURPOSE

To investigate any association between the presence of an adnexal cystic lymphangioma (ACL) and an enlarged leiomyomatous uterus.

METHODS

A retrospective observational study was conducted by two expert radiologists using a 10-year MRI database (2008-2018); 85 patients (mean age: 45.5 years ± 10.9) were considered eligible due to the presence of a single (n = 31) or multiple (n = 54) leiomyomas causing distortion of the uterine contour and uterine enlargement. The association of specific leiomyoma features (longest diameter (Dmax), location, number) and uterine volume with the presence of ACL was statistically tested. Diagnosis of ACL was based on typical imaging features (n = 14) and intraoperative/histological findings (n = 3).

RESULTS

ACL (unilateral = 9, bilateral = 8) was recorded in 17/85 (20%) of patients; it was more frequently observed when the largest leiomyoma was located in the uterine fundus (33.3%). Patients with ACL had significantly more leiomyomas (median: 5 vs. 2, p = 0.043), greater Dmax of largest leiomyoma (median: 13.3 vs. 7.2 cm, p < 0.001), and larger uterine volumes (median: 676.7 vs. 223.1 cm³, p < 0.001) compared to patients without ACL. ROC curve analysis for a number of leiomyomas showed that the optimal cut-off for the prediction of ACL was the presence of 5 leiomyomas with 53.8% sensitivity and 84% specificity (AUC = 0.65, 95% CI 0.51-0.83, p = 0.049), Dmax of largest leiomyoma 9.1 cm with 76.5% sensitivity and 77.9% specificity (AUC = 0.83, 95% CI 0.73-0.94, p < 0.001), and uterine volume 311 cm³ with 71% sensitivity and 75% specificity (AUC = 0.79, 95% CI 0.66-0.92, p < 0.001).

CONCLUSIONS

The presence of ACL is significantly associated with number of leiomyomas, Dmax of largest leiomyoma, and uterine volume; prospective evaluation of our results is needed to investigate its clinical significance.

Cross-sectional imaging of acute gynaecologic disorders: CT and MRI findings with differential diagnosis-part II: uterine emergencies and pelvic inflammatory disease

Due to the growing use of cross-sectional imaging in emergency departments, acute gynaecologic disorders are increasingly diagnosed on urgent multidetector computed tomography (CT) studies, often requested under alternative presumptive diagnoses in reproductive-age women. If clinical conditions and state-of-the-art scanner availability permit, magnetic resonance imaging (MRI) is superior to CT due to its more in-depth characterisationof abnormal or inconclusive gynaecological findings, owing to excellent soft-tissue contrast, intrinsic multiplanar capabilities and lack of ionising radiation.

This pictorial review aims to provide radiologists with a thorough familiarity with gynaecologic emergencies by illustrating their CT and MRI appearances, in order to provide a timely and correct imaging diagnosis. Specifically, this second instalment reviews with examples and emphasis on differential diagnosis the main non-pregnancy-related uterine emergencies (including endometrial polyps, degenerated leiomyomas and uterine inversion) and the spectrum of pelvic inflammatory disease.

Nonovarian Mimics of Ovarian Malignancy

Once a pelvic mass is identified on an ultrasound examination, the first step in the differential diagnostic work up is to determine its origin. Most lateral pelvic masses in women are ovarian in origin, and the distinction between ovarian and nonovarian mimics of ovarian cancer is critical for appropriate clinical and surgical management. Adnexal masses detected on ultrasound can be further characterized by magnetic resonance imaging (MRI) when needed. Superior contrast resolution, multiplanar imaging, characteristic signal intensity of common pathology such as dermoid tumors or endometriomas allows one to accurately evaluate adnexal tumors with supplemental use of MRI. Commonly encountered extraovarian abnormalities that mimic ovarian malignancies are categorized as being either predominantly cystic or solid. The common causes of such extraovarian lesions that mimic ovarian pathology include fallopian tube diseases, paroaovarian cysts, peritoneal inclusion cysts, and a pedunculated or a broad ligament fibroid. Less common causes of cystic and solid nonovarian mimics of ovarian malignancy include mucocele of the appendix, lymphocele, spinal meningeal cysts, extraovarian endometriomas, extraovarian fibrothecomas, and gastrointestinal stromal tumors (Table 1). Identifying a normal appearing ovary is the key in distinguishing an extraovarian pelvic mass from an ovarian tumor. This becomes particularly challenging in postmenopausal women with atrophic ovaries. In this scenario, MRI comes into use by identifying small atrophic ovaries more often than ultrasound is able to. Extraovarian lesions typically displace the pelvic sidewall vasculature medially, ureters tend to be compressed, encased or medially displaced, enhancement matches pelvic arteries and may be associated with engorged mesenteric vessels compared to gonadal vessel engorgement seen with ovarian tumors.

Accessory cavitated uterine mass: MRI features and surgical correlations of a rare but under-recognised entity

OBJECTIVES

To describe MRI features of accessory cavitated uterine mass (ACUM) with surgical correlations.

METHODS

Eleven young women with an ACUM at pathology underwent preoperative pelvic MRI. Two experienced radiologists retrospectively analysed MR images in consensus to determine the lesion location within the uterus, its size, morphology (shape and boundaries), and structure reporting the signal and enhancement of its different parts compared to myometrium. The presence of an associated urogenital malformation or other gynaecological anomaly was reported. MRI features were correlated with surgical findings.

RESULTS

All 11 lesions were well correlated with surgical findings, lateralised (seven were left-sided), and located under the horn and the round ligament insertion. Nine were located within the external myometrium, bulging into the broad ligament. Two were extrauterine, entirely located within the broad ligament. On MRI, the mean size was 28 mm (range 17-60 mm). Nine lesions were round-shaped, two were oval; all had regular boundaries. At surgery, the ACUM were not encapsulated but were possible to enucleate. On MRI, all lesions were well defined and showed a central haemorrhagic cavity surrounded by a regular ring (mean thickness, 5 mm) which had the same signal compared to the junctional zone. ACUM was isolated in all women, without urogenital malformation, adenomyosis or deep endometriosis.

CONCLUSIONS

On MRI, ACUM was an isolated round accessory cavitated functional non-communicating horn-like aspect in an otherwise normal uterus. MRI may facilitate timely diagnosis and appropriate curative fertility-sparing laparoscopic resection.

KEY POINTS

• ACUM is rare, with delayed diagnosis in young women with severe dysmenorrhoea. Pelvic MRI facilitates timely diagnosis and appropriate curative fertility-sparing laparoscopic resection. • Quasi-systematically located under the uterine round ligament insertion, ACUM may be intramyometrial and/or in the broad ligament. • On MRI ACUM resemble a non-communicating functional accessory horn within a normal uterus; the mass, most often round-shaped, had a central haemorrhagic cavity surrounded by a regular ring which had the same low signal compared to the uterine junctional zone.

Huge (9 Kg) Broad Ligament Fibroid Mimicking Sarcoma of Uterus: A Case Report and Review of Literature

Fibroids are most common benign tumors of the uterus, mostly situated in the body of the uterus. Rarely, they arise from extrauterine sites with broad ligament fibroids being uncommon. We present a case of a 47-year-old female, multipara who presented in outpatient department in CAMA hospital with a history of sudden development of dysuria 10 days back. Intraoperatively, uterus was pushed to side and large broad ligament fibroid of 25 cm × 20 cm × 20 cm seen arising from right-sided broad ligament. The fibroid was densely adherent to bowel and bladder. Exploratory laparotomy with excision of broad ligament fibroid of 9 Kg with total abdominal hysterectomy with right salpingo-oophorectomy was done.

Nongynecologic Findings Seen at Pelvic US

Ultrasonography (US) is frequently the first imaging modality used to examine women with symptoms involving the pelvis. It is widely available and involves no exposure to ionizing radiation. Images can be acquired with a transabdominal, endovaginal, or translabial approach, and the use of video clips and three-dimensional reconstructions can be helpful. US is excellent for assessment of the uterus, ovaries, and adnexa. Occasionally, nongynecologic pelvic diseases arising from the gastrointestinal, genitourinary, and musculoskeletal systems and the pelvic peritoneal and extraperitoneal spaces may be detected and can be a source of diagnostic dilemma. US can be helpful not only in the detection but also occasionally in the characterization of such entities. Computed tomography and magnetic resonance imaging are useful in complicated cases. In this article, the normal US appearance of the bowel and US signs of bowel disease and specific entities, including appendicitis, diverticular disease, bowel obstruction, appendiceal mucocele, and intestinal tumors, are reviewed. The lower urinary tract is included in the field of view in every pelvic US examination; commonly encountered entities related to the urinary bladder, distal ureter, and urethra are illustrated. In addition to arising in the gastrointestinal and genitourinary tracts, pathologic conditions in the pelvis can arise in the peritoneal or extraperitoneal space. Although conditions of the pelvic peritoneal and extraperitoneal spaces are rare, it is important to recognize these entities and distinguish them from the more common gynecologic diseases. Owing to the implications for diagnosis and management, radiologists and other physicians who perform pelvic US should be aware of the spectrum of nongynecologic pathologic entities that can be detected. ©RSNA, 2017.

A subserosal, pedunculated, multilocular uterine leiomyoma with ovarian tumor-like morphology and histological architecture of adenomatoid tumors: a case report and review of the literature

Background

Uterine leiomyomas are common uterine tumors, and typical cases of leiomyoma are easily diagnosed by imaging study. However, uterine leiomyomas are often altered by degenerative changes, which can cause difficulty and confusion in their clinical diagnosis. We describe the 17th reported case of a uterine leiomyoma clinically diagnosed as an ovarian tumor; however, the present case shows the most detailed radiological evaluation, including contrast-enhanced magnetic resonance imaging. We first show that a uterine leiomyoma can histologically mimic an adenomatoid tumor.

Case presentation

A 47-year-old premenopausal, nulliparous Japanese woman with a history of type 2 diabetes mellitus, hypertension, and hyperlipidemia had lower abdominal pain. Ultrasonography confirmed a 6-cm mass in the right-sided space of the pelvic cavity. Magnetic resonance imaging evaluation showed that a multilocular mass was present near the uterus, and a mucinous ovarian tumor was considered. Emergency surgery due to acute abdomen was performed under the diagnosis of pedicle torsion of the ovarian tumor. During surgery, a pedunculated uterine mass without stalk torsion was seen. The mass grossly contained serous and hemorrhagic fluids in the cavities, and pathology examination confirmed that the mass was a leiomyoma with hydropic and cystic degeneration. Anastomosing thin cord-like arrangements of the leiomyoma cells mimicked the architecture of adenomatoid tumors. The tumor cells were positive for the microphthalmia transcription factor but negative for other melanoma markers. Three days postoperatively, she was discharged without sequelae.

Conclusions

Marked intratumoral deposition of fluids may induce the multilocular morphology of a tumor, and the cellular arrangement of the tumor cells with hydropic degeneration mimicked an adenomatoid tumor in this case. Clinicians need to be aware that a subserosal leiomyoma with cystic and hydropic degeneration can mimic an ovarian tumor, and pathologists should be aware that such leiomyomas can mimic adenomatoid tumors. Additionally, perivascular epithelioid cell tumors should not be diagnosed only based on its immunoreactivity for the microphthalmia transcription factor.

Beyond hepatic hemangiomas: the diverse appearances of gastrointestinal and genitourinary hemangiomas

Hemangiomas are common lesions, best known for their appearance in the liver. Their appearance in less common locations, such as the gastrointestinal and genitourinary tracts, is less well known. We will review the typical and atypical appearance of hemangiomas in these locations on sonography, CT, and MRI.

Magnetic resonance imaging of acquired disorders of the pediatric female pelvis other than neoplasm

Transabdominal US remains the primary screening imaging modality of the pediatric female pelvis. However, MRI has become an invaluable adjunct to US in recent years. MRI offers superb soft-tissue contrast resolution that allows for detailed evaluation, particularly of the ovaries and their associated pathology. MRI can yield diagnostic information that is similar to or even better than that of US, especially in nonsexually active girls in whom transvaginal US would be contraindicated. MRI is generally a second-line examination and is preferred over CT because it does not involve the use of ionizing radiation. MRI might be underutilized in this population, particularly in differentiating surgical from nonsurgical conditions. This article reviews the relevant anatomy and discusses imaging of acquired conditions that involve the pediatric female genital tract, illustrating associated pathology with case examples.

Perineural (Tarlov) Cyst Imitating Complex Adnexal Cyst

Patients are frequently referred for pelvic sonograms to evaluate for adnexal masses. Determining the etiology of the adnexal mass can be challenging, but is necessary to establish a follow-up strategy and correct diagnosis. It is particularly important in those cases when adnexal lesions appear to be complex and the ovaries are not visualized sonographically. Perineural cysts were found incidentally by Tarlov in 1938 during autopsy. This report documents a lesion now bearing his name, Tarlov cysts (TCs). They are defined as cerebrospinal fluid–filled saccular lesions located in the extradural space of the sacral spinal canal and are formed within the nerve root sheath at the dorsal root ganglion. The perineurium and neural tissue make up the cysts’ walls. Usually asymptomatic, a TC is mostly found on magnetic resonance imaging (MRI) of the lumbar spine and sacrum. Occasionally, a TC mimics an adnexal cyst.

Mesenteric lymphangioma mimicking a cystic ovarian mass on imaging

Pelvic cystic masses are frequently observed in women. Most lesions are benign and of ovarian origin. However, non-ovarian lesions can be easily confused with cystic ovarian masses on imaging, which hampers diagnostic and therapeutic management. In this report, a rare case of mesenteric lymphangioma mimicking an ovarian cystic mass, discovered as an incidental finding on orthopaedic MRI in an adult female, is presented. The report highlights the sometimes difficult diagnostic process of pelvic cystic masses, due to an extensive differential diagnosis and the fact that imaging is often inconclusive. Even though most cystic masses are of ovarian origin, non-ovarian causes can mimic ovarian masses and should be considered as differential diagnoses. Surgical exploration may be necessary to exclude malignant causes.

Primary and secondary disease of the peritoneum and mesentery: review of anatomy and imaging features

The largest and most complex serosal membrane in the body, the peritoneum, lines the abdominal cavity, and the abdominopelvic viscera. It is frequently involved in a variety of benign and malignant processes. While secondary involvement of the peritoneum is more common, primary tumors can be a diagnostic challenge. Knowledge of the anatomy is crucial in understanding the various pathologic processes. Cross-sectional imaging plays an important role in diagnosing and evaluating the extent of the disease processes. This article reviews the imaging anatomy of the peritoneum and mesentery and the common pathologies involving it.

Rare case of endometrioid adenocarcinoma arising from cystic adenomyosis

Few reports on malignant transformation of adenomyosis are available, and endometrioid adenocarcinoma arising from cystic adenomyosis is further rarely reported. We report a case of a 67-year-old asymptomatic woman who was referred to our hospital for evaluation of a cystic lesion in the pelvis, which had been diagnosed as cystic degeneration of leiomyoma for 3 years. Magnetic resonance imaging revealed a cystic mass measuring 11 cm in diameter, which was contiguous with uterine myometrium. The lesion contained solid areas enhanced on gadolinium-enhanced T1 -weighted imaging. Transabdominal simple total hysterectomy with bilateral salpingo-oophorectomy was performed. Pathological examination revealed endometrioid adenocarcinoma arising from cystic adenomyosis. The patient underwent six courses of adjuvant combination chemotherapy with paclitaxel and carboplatin. No metastasis or recurrence has been demonstrated for 16 months following surgery. Our case demonstrates that cystic adenomyoma possesses the risk of malignant transformation, indicating the importance of long-term follow-up with imaging examination.

Peritoneal inclusion cysts in female children: pathogenesis, treatment, and multimodality imaging review

We report the multimodality imaging findings of peritoneal inclusion cysts in two adolescent females each with a prior history of abdominal surgery. The few reports of peritoneal inclusion cysts in the pediatric population have largely focused on the clinical and pathological features of this entity. We wish to emphasize the imaging findings of peritoneal inclusion cysts on multiple modalities, the advantage of MRI in confirming the diagnosis, and the need to keep considering this diagnosis in patients who present with a pelvic cystic mass, with a history of surgery, even if remote. Additionally, we review the pathology, pathophysiology, differential diagnosis, and treatment options of peritoneal inclusion cysts.

MRI appearances of benign uterine disease

Benign uterine disease is a common entity affecting women of all ages. Ultrasound has historically been the predominant imaging method used in the evaluation of benign gynaecological disease, magnetic resonance imaging (MRI) being reserved for use in the staging of malignant uterine and cervical disease. MRI is now increasingly used in the diagnosis of benign uterine disease as well as a tool for problem-solving in cases of diagnostic dilemma. It allows detailed assessment of benign conditions, such as endometrial lesions, leiomyomas, and adenomyosis, and can be helpful in the stratification of patients to different treatment modalities, including surgical resection, uterine artery embolization, and medical therapies. In this article, we review the MRI findings in the common benign uterine diseases.

Peritoneal inclusion cysts in pregnancy, a diagnostic challenge

A cystic pelvic mass detected during pregnancy is not uncommon, but can be a diagnostic challenge. Most of these pelvic masses are benign ovarian cysts and resolve spontaneously. However, rare non-ovarian causes can complicate the diagnostic and therapeutic management. In this report an unusual case is presented of a 27-year-old pregnant woman with an atypical multicystic lesion in the pelvis, seen on routine first trimester ultrasound. A laparoscopic exploration was performed to rule out ovarian malignancy, and after histological analysis she was diagnosed with peritoneal inclusion cysts. The diagnostic and therapeutic challenges inherent to this rare non-ovarian disease are addressed in this case report.

A case of massive broad ligament leiomyoma imitating an ovarian tumour

Leiomyomas are the most common benign tumours of female reproductive system which occur in women of child- bearing ages. Large fibroids are known to arise from uterus, but rarely from broad ligament. An unusual clinical presentation of a massive, broad ligament fibroid which measured 25 cm x 22 cm x 21 cm, and imitated an ovarian tumour because of its myxoid and cystic degenerations, has been described.