"Ovarian vascular pedicle" sign revealing organ of origin of a pelvic mass lesion on helical CT

Retroperitoneal leiomyosarcoma mimicking an ovarian tumor diagnosed using a negative ovarian pedicle sign

Retroperitoneal leiomyosarcoma (RPLMS) is rare and usually presents as a large abdominal mass with poor clinical symptoms. Radiological findings of an RPLMS arising in the pelvis of a woman resemble those of adnexal tumors. Herein, we present a case of RPLMS mimicking an adnexal tumor which was differentiated from having an ovarian origin as the right ovarian vein was passing through the tumor but there was no direct vascular connection with the tumor. Therefore, it is important to identify the ovarian vein to distinguish between these tumors.

'That's just the Ovary!' and other cases of mistaken identity on CT of the female pelvis

CT is often the first imaging test in female patients with lower abdominal and pelvic pain because of the wide availability of CT and differential diagnoses that span both gynecologic and gastrointestinal disease. Pathology within the female pelvis may be difficult to diagnose on CT owing to suboptimal delineation of anatomy in comparison to MRI and ultrasound. These challenges are confounded by overlapping imaging features of a wide range of gynecologic entities and can lead to diagnostic dilemmas. High value CT interpretation will direct the clinician to the best next diagnostic step as ultrasound and MRI provide superior soft tissue delineation. Other imaging modalities, laboratory investigations, or tissue sampling may be necessary to definitively characterize indeterminate lesions. In this review, we illustrate various cases of mistaken identity on CT of the female pelvis involving the ovaries, uterus, and peritoneal cavity while highlighting clinical pearls that may aid the radiologist in arriving at the correct diagnosis and avoiding potential pitfalls.

O-RADS MRI risk stratification system: pearls and pitfalls

In 2021, the American College of Radiology (ACR) Ovarian-Adnexal Reporting and Data System (O-RADS) MRI Committee developed a risk stratification system and lexicon for assessing adnexal lesions using MRI. Like the BI-RADS classification, O-RADS MRI provides a standardized language for communication between radiologists and clinicians. It is essential for radiologists to be familiar with the O-RADS algorithmic approach to avoid misclassifications. Training, like that offered by International Ovarian Tumor Analysis (IOTA), is essential to ensure accurate and consistent application of the O-RADS MRI system. Tools such as the O-RADS MRI calculator aim to ensure an algorithmic approach. This review highlights the key teaching points, pearls, and pitfalls when using the O-RADS MRI risk stratification system.Critical relevance statement This article highlights the pearls and pitfalls of using the O-RADS MRI scoring system in clinical practice.Key points• Solid tissue is described as displaying post- contrast enhancement.• Endosalpingeal folds, fimbriated end of the tube, smooth wall, or septa are not solid tissue.• Low-risk TIC has no shoulder or plateau. An intermediate-risk TIC has a shoulder and plateau, though the shoulder is less steep compared to outer myometrium.

Manifestations of Ovarian Cancer in Relation to Other Pelvic Diseases by MRI

Imaging plays a pivotal role in the diagnostic approach of women with suspected ovarian cancer. MRI is widely used for preoperative characterization and risk stratification of adnexal masses. While epithelial ovarian cancer (EOC) has typical findings on MRI; there are several benign and malignant pelvic conditions that may mimic its appearance on imaging. Knowledge of the origin and imaging characteristics of a pelvic mass will help radiologists diagnose ovarian cancer promptly and accurately. Finally, in special subgroups, including adolescents and gravid population, the prevalence of various ovarian tumors differs from that of the general population and there are conditions which uniquely manifest during these periods of life.

Hypermetabolic Subserosal Uterine Leiomyoma With Synchronous Atypical Multiple Myeloma Mimicking Ovarian Malignancy With Multiple Bone Metastases on 18F-FDG PET/CT

ABSTRACT

Subserosal cystic myoma with intense FDG uptake can resemble malignant cystic ovarian tumor and may lead to a false-positive diagnosis. A 49-year-old woman presented with chest pain for 4 months, and the initial chest CT showed multiple bone lesions. 18F-FDG PET/CT revealed not only multiple osteolytic lesions with FDG uptake but also a highly FDG-avid mass abutting the right side of the uterus. Ovarian malignancy with multiple bone metastases was considered initially. Subsequent biopsy confirmed multiple myeloma, and a subserosal uterine myoma was diagnosed by transvaginal sonography.

[Radiologic Evaluation of Uterine Lesions Using a Pattern Recognition Approach]

It is important to distinguish uterine lesions from other lesions occurring in the pelvic cavity for the proper management. The primary radiological evaluation of uterine lesions is performed using transvaginal ultrasonography, and if the lesion is too large or shows atypical benign imaging findings, magnetic resonance imaging should be performed. Analyzing radiological findings of uterine lesions through a pattern recognition approach can help establish the accurate diagnosis and treatment plan. In this pictorial assay, we describe imaging characteristics of various lesions arising from the uterus and evaluate them based on the pattern recognition approach.

Computed Tomography and Clinical Analysis of Ovarian Mucinous Tumors in Adolescent Patients

STUDY OBJECTIVE

To investigate the clinical and computed tomography features of ovarian mucinous tumors in children and adolescents.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective analysis of clinical and preoperative computed tomography (CT) data was performed in 59 patients who were 20 years or younger with ovarian mucinous tumors confirmed by histopathology. Patients' age, medical history, symptoms, tumor marker levels, and CT imaging findings were recorded.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Identification of the clinical and CT features of ovarian mucinous tumors in pediatric and adolescent patients.

RESULTS

There were 41 mucinous cystadenomas in 39 cases, 12 borderline mucinous cystadenomas in 11 cases, and 9 mucinous cystadenocarcinomas in 9 patients. A total of 55 tumors were multilocular (55/62, 88.7%), including fewer than 10 loculations in 23 tumors, 10-20 loculations in 17 tumors, and over 20 loculations in 15 tumors. Eleven borderline mucinous cystadenomas were multilocular (11/12, 91.7%), with over 10 loculations in 7 tumors (7/12, 58.3%). Twelve tumors appeared as multilocular cystic-solid (12/62, 19.4%), and a case of mucinous cystadenocarcinoma was predominantly solid (1/62, 1.6%). Seventeen tumors showed honeycomb sign and stained glass appearance. Six mural nodules, with sizes ranging from 1.1 to 3.5 cm (average: 2.8 cm), were found in borderline mucinous cystadenoma and mucinous cystadenocarcinoma.

CONCLUSIONS

The CT findings of ovarian mucinous tumors in children are characteristic. The preoperative CT is helpful in making differential diagnoses.

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.

Multimodality imaging review of complex pelvic lesions in female pelvis

Complex pelvic lesions can originate from various anatomical structures in the pelvis and pose a diagnostic dilemma due to a wide range of possible diagnoses. Accurate characterisation of these lesions would often require an algorithmic approach, which incorporates clinical findings, sequential use of multiple imaging modalities and a multiparametric approach. This approach usually aims at identifying key imaging features, which aid in anatomical localisation, morphology and tissue characterisation. There have been various attempts to standardise the lexicon used for describing adnexal masses in female patients; stratify their risk of cancer and suggest appropriate next steps in the management pathway. Through this review, we extend this approach to complex pelvic masses in female pelvis in general and will focus on optimal use of different imaging modalities to arrive at definitive diagnosis or meaningful differential diagnosis. We will also discuss potential pitfalls of imaging diagnosis and common mimics.

MRI of Tumors and Tumor Mimics in the Female Pelvis: Anatomic Pelvic Space-based Approach

Pelvic masses can present a diagnostic challenge owing to the difficulty in assessing their origin and the overlap in imaging features. The majority of pelvic tumors arise from gastrointestinal or genitourinary organs, with less common sites of origin including the connective tissues, nerves, and lymphovascular structures. Lesion evaluation usually starts with clinical assessment followed by imaging, or the lesion may be an incidental finding at imaging performed for other clinical indications. Since accurate diagnosis is essential for optimal management, imaging is useful for suggesting the correct diagnosis or narrowing the differential possibilities and distinguishing tumors from their mimics. Some masses may require histologic confirmation of the diagnosis with biopsy and/or up-front surgical resection. In this case, imaging is essential for presurgical planning to assess mass size and location, evaluate the relationship to adjacent pelvic structures, and narrow differential possibilities. Pelvic US is often the first imaging modality performed in women with pelvic symptoms. While US is often useful to detect a pelvic mass, it has significant limitations in assessing masses located deep in the pelvis or near gas-filled organs. CT also has limited value in the pelvis owing to its inferior soft-tissue contrast. MRI is frequently the optimal imaging modality, as it offers both multiplanar capability and excellent soft-tissue contrast. This article highlights the normal anatomy of the pelvic spaces in the female pelvis and focuses on MRI features of common tumors and tumor mimics that arise in these spaces. It provides an interpretative algorithm for approaching an unknown pelvic lesion at MRI. It also discusses surgical management, emphasizing the value of MRI as a road map to surgery and highlighting anatomic locations where surgical resection may present a challenge. ^©RSNA, 2019.

Multimodality imaging and genomics of granulosa cell tumors

OBJECTIVE

The purpose of this article is to review the imaging findings and genomics of granulosa cell tumors (GCTs) in order to aid in diagnosis and management of GCTs. GCTs are the most common type of sex cord-stromal tumors of the ovary. They are usually diagnosed initially with ultrasound and are subsequently further characterized with CT and MRI. PET/CT is often ordered as well to measure the extent of disease and for follow-up, but its usefulness is in question as some GCTs lack FDG avidity. There is significant variability in imaging phenotypes of GCTs, ranging from mostly cystic to almost solid. More resources have recently been dedicated to understanding the genetics and molecular mechanisms of GCT development. Current research shows that the main cause of GCT carcinogenesis is the FOXL2 mutation, but there are several other noteworthy mutations that contribute to the pathogenesis of this disease. Certain mutations, like GATA4, are known to be associated with more aggressive disease and higher rates of recurrence.

CONCLUSION

Using this information, imaging protocols can be altered depending on the genotype of the tumor. Further understanding of the genetic alterations that underpin the development of GCTs is indicated as genotypic knowledge could be used to guide optimal imaging and management strategies.

Management Driven Structured Reporting in Ovarian Cancer

Since majority (80%) of ovarian cancer patients present at an advanced stage, imaging performed on these patients have numerous findings. The combination of multiple findings on imaging, complexity of anatomical structures which are involved in ovarian cancer, and the need to perceive certain subtle imaging features which would impact management often makes it challenging to systematically review images of these patients. Similarly, it is difficult to effectively communicate these findings in radiology reports. Structured reporting that is geared toward clinical decision-making has been an area of recognized need. An understanding of the review areas, which aid clinical decision-making in a multidisciplinary team setting at our institution led us to the proposed structured reporting template for ovarian cancer. Through this review, the authors would like to share this reporting template with examples.

Adnexal incidentalomas on multidetector CT: how to manage and characterise

Although CT is not considered the examination of choice for the detection and characterisation of adnexal diseases, adnexal masses may be incidentally detected during CT examination performed for other clinical indications. Most adnexal incidentalomas are benign, and therefore may not require further investigation, follow-up or intervention; however, few of them may prove malignant. Multidetector CT has improved the diagnostic performance of the technique in the detection and differentiation of adnexal mass lesions. Radiologists should be able to recognise the normal CT appearance of the ovaries and the CT characteristics of various adnexal incidentalomas. This may obviate unnecessary imaging evaluation and allow optimal treatment planning. Regarding the management of adnexal lesions incidentally found on CT, recommendations based on the collective experience of the members of the American College of Radiology Incidental Findings Committee II have recently been presented.

Angiographic evaluation of the internal iliac artery branch in pelvic tumour patients: Diagnostic performance of multislice computed tomography angiography

The aim of the present study was to explore the classification of the internal iliac artery (IIA) and the diagnostic value of the pelvic tumour-feeding artery by multislice computed tomography angiography (MSCTA) compared with digital subtraction angiography (DSA). A total of 43 patients with pelvic tumours were enrolled between January 2013 and August 2017. The classification of the IIA and the quality of the feeding artery of the pelvic tumours were analysed by Yamaki's classification (Groups A-D according to IIA branching) and the 5-point scoring system. The degree of feeding artery stenosis, caused by tumour compression or invasion, was analysed by a 4-point scoring system. The Wilcoxon signed-rank test was used to determine the vascular diagnostic quality identified by MSCTA and DSA. MSCTA of the pelvic arteries was successfully performed in all patients. The main classifications of the IIA were Group A, followed by Group C, then Group B and with no cases of Group D. There was no significant difference in the classification of the IIA between the left and right sides on MSCTA and DSA. The visualization quality of the IIA and its main branches showed excellent consistency, but the difference in the terminal branches of the feeding arteries in the pelvic tumours was statistically significant between MSCTA and DSA. MSCTA has great advantages in evaluating the classification of the IIA, the imaging quality evaluation of the IIA and its main branches, and in the evaluation of the pelvic tumour-feeding artery. However, in the display of the terminal arterial branches of the pelvic tumours, DSA remains irreplaceable, particularly in cases of interventional embolization.

Torsion of Ovarian Dysgerminoma in a Child: Role of Computed Tomography

Dysgerminomas are malignant germ cell tumors of the ovary that most commonly occur in the adolescent population. Ovarian dysgerminoma presenting with complications like torsion is a rare entity in the pediatric age group. Cross-sectional imaging plays a crucial role in diagnosis, tumor staging before surgical resection, and for planning adjuvant chemotherapy. We report a case of a nine-year-old female who presented to the emergency room (ER) with abdominal distention and abdominal pain. Computed tomography scan revealed a large right-sided pelvic mass with areas of low attenuation, speckled calcification, peritumoral free fluid, and a twisted vascular pedicle that was likely originating from the left adnexa. The right ovary was normal in appearance. Suspicion of a left-sided ovarian tumor with torsion was raised, which was later confirmed on surgery and histopathology of the resected specimen.

[Gynecological tumors of the true pelvis: Radiological diagnosis for pelvic tumors made simple]

Tumors of the reproductive organs are among the most common female tumors. Computed tomography (CT) and magnetic resonance imaging (MRI) are used for establishing the differential diagnosis, for staging and increasingly for treatment stratification. Sonography is the first line imaging modality for assessing benign and malignant tumors of the uterus as well as ovarian and adnexal lesions. In sonographically indeterminate masses MRI is used for clarification as it allows not only a prediction of the dignity but also in most cases a specific diagnosis. The MRI examination is also superior to CT in the assessment of tumors resembling benign pelvic lesions. Whereas MRI has become established as the modality of choice for local staging and treatment planning in cancers of the uterine cervix and endometrial cancer, CT is used for staging of ovarian cancer due to the propensity for peritoneal spread outside the pelvis at the time of initial diagnosis.

CT diagnosis in the thecoma-fibroma group of the ovarian stromal tumors

The aim of this study was to investigate characteristic CT manifestations of the group of ovarian thecoma-fibroma. 24 patients (26 lesions) presenting with the ovarian thecoma-fibroma were analyzed retrospectively, and the diagnosis were confirmed by pathology after surgery. Our findings included: 22 patients were unilateral, while 2 were bilateral; 12 lesions were located in the right side of ovary, while 14 lesions were in the left side. Of the 26 lesions, there were ovarian thecoma (16 lesions), fibrothecoma (6 lesions), and fibroma (4 lesions). The largest diameters of tumor ranged from 37 to 231 mm with the mean value of 100 ± 44.29 mm. 14 patients were accompanied by ascites. All the tumors had well-defined borders. The shape of  22 lesions appeared round or oval, and 4 lesions were irregular. The tumors were solid in 19 lesions, cystic in 2 lesions, and mixed in 5 lesions. Most of the tumors were of heterogeneous density. There were no (20 lesions) or slight enhancement (6 lesions) after injection of the contrast medium. CT values of plain scan, arterial phase and venous among three groups had no significant difference. The enhancement were in the range of 0-5 HU in 10 lesions, and 6-17 HU in 16 lesions. In conclusion, the characteristic CT manifestations of the group of ovarian thecoma-fibroma were: often unilateral solid mass with the shape of oval and well defined border; no enhancement or slight enhancement; accompanied by small amount of ascites.

Determining the organ of origin of large pelvic masses in females using multidetector CT angiography and three-dimensional volume rendering CT angiography

OBJECTIVE

To study the value of tumour feeding arteries and the ovarian vein in determining the organ of origin of large pelvic tumours in females using multidetector CT.

METHODS

One hundred and thirty patients with 131 pathologically proven tumours (>6.5 cm) were retrospectively reviewed. Conventional CT images and CT angiography were evaluated, with focus on assessing the value of tumour feeding arteries and the ovarian vein in differentiating ovarian from non-ovarian tumours.

RESULTS

For 97 ovarian tumours, the feeding arteries included the ovarian artery (n = 51) and the ovarian branch of uterine artery (n = 64). For 34 non-ovarian tumours, the feeding arteries included the ovarian artery (n = 2), the uterine artery (n = 21), the mesenteric artery (n = 5), and the internal iliac artery (n = 1). The ovarian vein was identified in 86 ovarian tumours and 12 non-ovarian tumours. When the feeding arteries and the ovarian vein were combined to confirm ovarian origin, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 97.8 %, 84.2 %, 93.8 %, 94.1 %, and 93.9 %, respectively. The accuracy was significantly higher than that of independently using the ovarian vein or the ovarian feeding arteries.

CONCLUSION

Combined application of tumour feeding arteries and the ovarian vein is valuable to differentiate large ovarian from non-ovarian tumours.

KEY POINTS

• CT is a valuable modality for diagnosing pelvic tumours. • Determining the organ of origin is difficult for large pelvic tumours. • Contrast-enhanced CT and CT angiography are helpful in depicting abdominopelvic vessels. • Tracking tumour-associated vessels can help differentiate large ovarian from non-ovarian tumours.

Practical approach to MRI of female pelvic masses

OBJECTIVE

Female pelvic masses have a broad differential diagnosis, including benign and malignant neoplasms and nonneoplastic entities.

CONCLUSION

By using a systematic approach to the evaluation of a complex pelvic mass, including incorporating the clinical and surgical history, and by using multiparametric MRI to identify the anatomic origin, morphologic features, and tissue composition of a mass, a short meaningful differential diagnosis or definitive diagnosis can often be established.

Pelvic tumors with normal-appearing shapes of ovaries and uterus presenting as an emergency (Review)

Abdominal pain with an associated pelvic mass is a common problem in everyday practice. Concerns about ectopic pregnancy, torsion of an enlarged ovary or malignancy usually dominate the diagnostic evaluation. On physical and imaging examination, when a palpable painful mass is present in the pelvis and the two ovaries and uterus are detected in their normal anatomical locations, the content and origin of the lesions may be significant in narrowing the pre-operative differential diagnosis. Thus, the emergent pelvic indications discussed in this review should be considered. The causes of acute abdominal pain are few in number and therefore an accurate diagnosis may be most frequently made at the time of exploratory laparotomy.

Demonstration of normal and dilated testicular veins by multidetector computed tomography

Recent advances in multidetector computed tomography (MDCT) technology enabled better visualization of testicular (gonadal) vein using submillimeter slice thickness and three-dimensional images. Normally, the testicular vein measures 1-3 mm and drains into the inferior vena cava and left renal vein on the right and left sides, respectively. They can be seen in most patients during MDCT studies. Curved planar and volume-rendered images can be used to display testicular veins. We aim to demonstrate MDCT findings of normal testicular vein and its pathologies including varicocele, varices, the testicular vascular pedicle sign, and phlebolith. The testicular vein can be dilated owing to varicocele or portal hypertension and in patients with intraabdominal seminomas arising from undescended testis. The testicular vein can also cause ureteral compression at the crossing point. Understanding MDCT findings of the normal testicular vein and its various pathologies can allow a correct diagnosis, thereby avoiding further diagnostic tests.

Omental vascular pedicle sign: multidetector CT finding useful for diagnosis of an omental mass

OBJECTIVE

To describe multidetector CT findings of "omental vascular pedicle" sign.

MATERIALS AND METHODS

"Omental vascular pedicle" sign was defined as dilated omental vein associated with a mass located in omentum and was observed in 7 patients (5 women, 2 men). Mean age was 45 years. CT examinations and patient records were retrospectively reviewed. CT images were obtained by 16-MDCT (n = 1) and 64-dual source MDCT (n = 6). Curved planar and volume rendered images were reconstructed from axial images. Diameter of omental vein and drainage site were recorded. Images were evaluated by 2 radiologists in consensus.

RESULTS

Pathologic diagnosis of patients with "omental vascular pedicle sign" was omental angiosarcoma (n = 1), endometrial adenocarcinoma (n = 2), ovarian serous adenocarcinoma (n = 2), mixed gonadal tumor (n = 1), malignant peripheral sheath tumor (n = 1). In 5 patients, omental vein drained into splenic vein and in 2 patients it drained into right gastroepiploic vein. Mean size of omental masses associated with omental vascular pedicle was 7.1 × 4.5 cm (range 15 × 11 cm to 2.7 × 1.6 cm). Mean diameter of omental vein was 3.1mm (range 6-1.5mm). Diameter of the omental vein increased with the increasing size of omental masses and Pearson's correlation coefficient was 0.99.

CONCLUSION

"Omental vascular pedicle sign" can be helpful to objectively diagnose omental masses in patients with primary and metastatic omental tumors.

Value of intra-adnexal and extra-adnexal computed tomographic imaging features diagnosing torsion of adnexal tumor

OBJECTIVE

The objective of this study was to evaluate the usefulness of the intra-adnexal and extra-adnexal computed tomographic (CT) features in identifying adnexal torsion.

PATIENTS AND METHODS

We retrospectively analyzed CT examinations of 38 adnexal masses with torsion and 270 without torsion, which has been surgicopathologically confirmed. The CT features were evaluated according to 2 categorized groups. The first group included the intra-adnexal features dealing with the ovary and uterine tube, whereas the other included the extra-adnexal features dealing with changes of adjacent anatomical structures such as the uterus, gonadal vein, and peritumoral zone. We acquired statistical proportions for the frequencies of these 2 groups of CT features in ovarian tumors with adnexal torsion versus those without adnexal torsion.

RESULTS

When there were intra-adnexal CT features of adnexal torsion, peculiar uterine tube thickening was identified in 74% of the lesions, eccentric or concentric wall thickening in 54% (of only cystic lesions), eccentric septal thickening in 50% (of only cystic lesions except mature cystic teratoma), and eccentric or diffuse decreased or poor contrast enhancement of the internal solid component or thickened wall in 50%. In extra-adnexal CT features of adnexal torsion, uterine deviation to the twisted side was identified in 61% of the lesions, peritumoral infiltration in 40%, nonvisualized anatomic continuity of the ipsilateral gonadal vein with the twisted adnexal mass in 71%, and ascites in 13%. There were significant differences in all of the intra-adnexal and extra-adnexal CT findings, except for ascites, between twisted and nontwisted adnexal tumors.

CONCLUSIONS

The intra-adnexal and extra-adnexal groups of CT features are valuable in identifying torsion of adnexal mass.

MDCT of the ovarian vein: normal anatomy and pathology

OBJECTIVE

We intend to show the MDCT findings of normal ovarian (gonadal) vein anatomy and associated disorders, including the "ovarian vascular pedicle" sign, phlebolith, reflux, pelvic congestion syndrome, thrombosis, stenosis, and occlusion.

CONCLUSION

Volume-rendered images and curved planar reformatted images can be used to show the ovarian veins. MDCT findings allow the diagnosis of various ovarian vein disorders in patients with abdominal and pelvic pain, pulmonary thromboembolism, and pelvic mass.

Value of magnetic resonance imaging for the diagnosis of ovarian tumors: a review

This article reviews the value of magnetic resonance imaging (MRI) for the diagnosis of ovarian tumors especially when ultrasonography is indeterminate. Although ultrasonography is the first imaging technique used to investigate suspected pelvic masses, it has a limited capacity for tissue characterization. In addition to morphological characteristics, many tissue parameters such as T1, T2, perfusion, and diffusion contribute to signal intensity, so MRI is able to identify various types of tissue contained in pelvic masses. Magnetic resonance imaging helps to locate large solid masses and to distinguish benign from malignant ovarian tumors, with an overall accuracy of 88% to 93% for the diagnosis of malignancy. The aims of this review are 3-fold. First, we review state-of-the-art and usual MRI techniques and published findings. Second, we recall the MR features most useful for assessing the main ovarian tumors. Finally, we discuss the relevance of various features for distinguishing between benign, borderline, and invasive ovarian tumors.

Hemodynamics of ovarian veins: MR angiography in women with uterine leiomyomata

PURPOSE

The passive reflux into ovarian veins (OVs) is well known as a common finding in normal asymptomatic women. The purpose of this study was to investigate the hemodynamics of OVs in women with myomatous uterus.

MATERIALS AND METHODS

Thirty-two women with symptomatic uterine leiomyomata underwent time-of-flight MR (TOF-MR) angiography, including venography and arteriography, and contrast-enhanced MRI. The frequency of reflux into OVs on TOF-MR angiography was retrospectively assessed with uterine volume, and compared to that of normal women in previous publication. The statistical evaluation was performed using Fisher's exact test.

RESULTS

The mean uterine volume was 932 +/- 612 ml (range, 301-2627 ml). The reflux into left OVs was observed in 4 of 32 women (13%) and that into right OVs was noted in 0 of 32 women (0%). These rates were significantly lower than those of normal asyptomatic women in the previous publication (p<0.05). The reflux into OVs was observed in 0 of 19 women (0%) with 600 ml or larger myomatous uterus, whereas it was noted in 4 of the remaining 13 women (31%) with less than 600 ml myomatous uterus, with significant difference between the two groups (p=0.02).

CONCLUSIONS

We found that reflux into OVs was infrequent in the vast majority of women with myomatous uterus, especially those with larger uterus due to leiomyomata on the basis of TOF-MR angiography. These findings suggested myomatous uterus could affect the flow direction of OVs, and passive reflux into OVs might be prevented due to the influence of antegrade flow of OVs.

Torsion of a uterine leiomyoma: MRI features

We report a case of a patient admitted to our hospital for acute pelvic pain. Ultrasounds and abdominal CT scan found a voluminous mass situated in the upper urinary bladder and contiguous to the uterus and to the ovaries. Magnetic resonance imaging identified a pedicle connecting the uterus to the mass which had an aspect of a necrobiotic leiomyoma. Laparoscopic surgery confirmed the diagnosis of acute torsion of a subserous uterine leiomyoma.

Detection of the gonadal veins in the diagnosis of transposed ovaries in patients with cervical carcinoma: a useful sign on MDCT

OBJECTIVE

The purpose of our study was to evaluate the detectability of the gonadal vein of transposed ovaries in patients with uterine cervical cancer on MDCT.

CONCLUSION

Gonadal veins and surgical clips of transposed ovaries can be shown with high consistency on MDCT. Tracking the gonadal veins and detecting the surgical clips may prevent the transposed ovaries from being misinterpreted as peritoneal implants.

Preoperative multidetector computed tomography diagnosis of a seminoma originating from an undescended testis by "testicular vascular pedicle" sign

We report a 65-year-old man with a palpable right lower quadrant mass who underwent multidetector computed tomography (MDCT) examination. Preoperative diagnosis of seminoma was possible by demonstration of "testicular vascular pedicle" sign by MDCT. We describe CT findings of the "testicular vascular pedicle" sign in this report.

Ovarian vascular pedicle sign in ovarian metastasis arising from gall bladder carcinoma

A case of a large mass in the pelvis confirmed to be a rare ovarian metastasis arising from a primary adenocarcinoma of the gall bladder is presented. The value of the recently described ovarian pedicle sign in confirming the organ of origin of the pelvic mass is emphasized.

Using the ovarian vein to find the ovary

Computed tomograms of 68 adult women who had undergone contrast-enhanced, 5-mm helical computed tomography of the abdomen and pelvis were retrospectively reviewed to determine whether the ovarian vein could be used to locate the ovary. Subjects were 17 to 84 years of age (mean 45 years); 31 scans were normal, and 37 showed pelvic masses. Both ovarian veins were identified at their termination and were followed into the pelvis by scrolling through the set of venous phase images with a manual cine-paging tool. All 68 left ovarian veins and 67 of 68 right ovarian veins were identified. All visualized ovarian veins led to a normal ovary or to an ovarian mass. There were no anatomic variations. In 13 ovaries displaced by pathology in the pelvis, the ovarian vein was correspondingly displaced and indicated the altered ovarian position. In all 14 patients with non-ovarian pelvic masses, ovarian veins led to the normal ovary; the vein and ovary were markedly displaced in three of these patients. On computed tomography, the ovarian vein can be consistently identified. By tracing the vein into the pelvis, the ovarian or non-ovarian nature of a pelvic mass can be determined.

MDCT of the Gonadal Veins in Females with Large Pelvic Masses: Value in Differentiating Ovarian Versus Uterine Origin

OBJECTIVE

The objective of our study was to determine the usefulness of recognizing the continuity of the gonadal veins to the pelvic mass to differentiate ovarian versus uterine origin on MDCT in females with a large pelvic mass.

MATERIALS AND METHODS

Two radiologists interpreted the MDCT images obtained on a monitor, using paging methods, in 86 female patients with a large pelvic mass (> 8 cm) and 40 patients without an abdominopelvic mass as control subjects. The following issues were recorded using a 5-point scale: visualization of gonadal veins and origin determination based on anatomic continuity. Receiver operating characteristic (ROC) curve analysis was performed, and the interobserver differences were checked with kappa statistics. The maximum diameters of the gonadal veins were also measured. With consensus interpretations, the sensitivity, specificity, and accuracy of ovarian origin determination were calculated.

RESULTS

Gonadal veins were shown in more than 70% of the subjects in both the control group and the patients with a mass (hereafter referred to as the "mass group"). There was no significant difference in the diameter of the gonadal veins between the control and mass groups and between patients with an ovarian mass and those with a uterine mass. The values for the area under the ROC curve (A(z)) of the two observers for ovarian origin determination were 0.90 and 0.92. The kappa value was 0.48. The sensitivity, specificity, and accuracy were 83.3%, 87.5%, and 84.9%, respectively.

CONCLUSION

Gonadal veins can be shown on MDCT with high consistency; MDCT provides useful information for determining the origin of relatively large pelvic tumors arising in females.

Acute torsion of uterine leiomyoma: CT features

Acute torsion of a subserosal leiomyoma is a rare acute condition that is infrequently diagnosed preoperatively. It is a recognized surgical emergency, especially when additional systemic symptoms are associated. There are two main differential diagnoses: ovary/adnexal torsion and massive infarct inside a common leiomyoma. The diagnosis can be established by computed tomographic features. Ultrasound examination is less sensitive.

Recognition of the Ovaries and Ovarian Origin of Pelvic Masses with CT

Knowledge of the morphologic features and ligamentous attachments of the ovaries, the relationship of the ovary to the ureter, and the course of the ovarian vein and artery is necessary for confident recognition of the ovaries and differentiation between ovarian and nonovarian masses with computed tomography (CT). The suspensory ligament attaches the ovary to the pelvic sidewall and transmits the ovarian vein and artery. This ligament may be seen at CT as a linear or fan-shaped soft-tissue band leading to the ovary. The utero-ovarian ligament is occasionally visualized with CT as a soft-tissue band between the uterus and ovary. The ovaries are usually located anterior or anteromedial to the pelvic ureters, whereas iliac lymph nodes are lateral or posterolateral to the ureters. Therefore, an ovarian mass displaces the ureter posteriorly or posterolaterally, whereas a large lymph node mass displaces the ureter medially or anteromedially. An ovarian mass may be draped by ovarian parenchyma, thus revealing the origin of the mass. Tracking the ovarian vein from near the level of the renal vessels caudally to the pelvis leads to the suspensory ligament region and is often helpful in identifying the ovary and differentiating ovarian and nonovarian masses.