Radiology course GINECOLOGICAL SYSTEM Clinical Case

Case 1 Female Acute pelvic pain Vaginal bleeding Reproductive age

First study? US pelvis trans vaginal US pelvis trans abdominal MR pelvis without contrast MR pelvis with/without contrast TC pelvis without contrast TC pelvis with/without contrast Case 1

In a clinically suspected ectopic pregnancy that is not confirmed on ultrasound, the differential is frequently that of a pregnancy of unknown location, with the alternative possibilities being of a very early pregnancy or a completed miscarriage. Case 1

Case 1

Ectopic pregnancy Case 1

Color and spectral doppler demonstrates a right anechoic tubal mass with fetal heart rate Ectopic pregnancy Case 1

The differential diagnosis of abdominal pain in a pregnant patient is broad. An ectopic pregnancy must be excluded with ultrasound. Other common diagnoses in this setting include: ruptured corpus luteum Appendicitis (negative beta hCG)

ruptured corpus luteum radiopaedia.org/articles/ectopic-pregnancy

appendicitis (negative beta hCG)

sacsearch.acr.org/docs/69503/Narrative

Case 2 Reproductive age Vaginal bleeding Pain Infertility Palpable masses

First study? US pelvis trans vaginal US pelvis trans abdominal MR pelvis without contrast MR pelvis with/without contrast TC pelvis without contrast TC pelvis with/without contrast Case 2

Case 2

Pelvic ultrasound ultrasound is used to diagnose the presence and monitor the growth of fibroids uncomplicated leiomyomas are usually hypoechoic, but can be isooechoic, or even hyperechoic compared to normal myometrium calcification is seen as echogenic foci with shadowing cystic areas of necrosis or degeneration may be seen

on CT images, fibroids are usually of soft tissue density but may exhibit coarse peripheral or central calcification they may distort the usually smooth uterine contour enhancement pattern is variable Case 2

Popcorn calcification within the pelvis may suggest the diagnosis. Case 2

Uterine fibroid classification

Case 2 A sub-mucosal leiomyoma of the uterus projects into the endometrial cavity. Submucosal leiomyomas can be a common source of abnormal uterine bleeding and may also present with reproductive dysfunction, including recurrent miscarriages, infertility, premature labour and / or fetal malpresentations. Submucosal leiomyoma

Case 2 intra-mural uterine leiomyoma is the most common type, usually asymptomatic. Intramural leiomyoma

Case 2 Sub-serosal uterine leiomyoma that often exophytically projects outwards from a sub- serosal location. Usually asymptomatic some pedunculated subserosal leiomyomas may undergo torsion, which results in infarction accompanied by pain Subserosal leiomyoma

MRI is not generally required for diagnosis, except for complex or problem solving cases. It is however the most accurate modality for detecting, localizing and characterising fibroids. Size, location and signal intensity should be noted. Case 2

acsearch.acr.org/docs/69458/Narrative

Reproductive age Pelvic pain Infertility ENDOMETRIOSIS

It is classically defined as the presence of functional endometrial glands and stroma outside the uterine cavity and musculature. It may vary from microscopic endometriotic implants to large cysts (endometriomas) Syntoms: Infertility; pelvic pain (not always cyclic): including dyspareunia, dysmenorrhea, chronic pelvic pain, urinary symptoms, rectal discomfort and dyschezia unusual symptoms: – gastrointestinal vesical or thoracic involvement Endometriosis

Endometriosis

Case 3 First study? US pelvis trans vaginal US pelvis trans abdominal MR pelvis without contrast MR pelvis with/without contrast TC pelvis without contrast TC pelvis with/without contrast Reproductive age Vaginal bleeding

Case 3

Ultrasound premenopausal – normal endometrial thickness depends on the stage of the menstrual cycle, but a thickness of >10 mm is top normal or abnormal – hyperplasia can be reliably excluded in patients only when the endometrium measures less than 6 mm. postmenopausal – a thickness of >5 mm is considered abnormal – The appearance can be non-specific and cannot reliably allow differentiation between hyperplasia and carcinoma. Usually there is a homogeneous increase in endometrial thickness, but endometrial hyperplasia may also cause asymmetric/focal thickening with surface irregularity, an appearance that is suspicious for carcinoma.

Case 4 -Female -65 years old Patient. -Vaginal bleeding as the initial symptom.

First study? US pelvis trans vaginal US pelvis trans abdominal MR pelvis without contrast MR pelvis with/without contrast TC pelvis without contrast TC pelvis with/without contrast Case 4

radiopaedia.org/articles/adenosquamous-carcinoma-of-endometrium Case 4

Transvaginal ultrasound is the initial imaging investigation of choice for patients presenting with the usual symptom of a postmenopausal bleed. A thickened endometrium requires endometrial sampling. Case 4

Case 4 A dedicated pelvic MRI protocol is recommended for optimal assessment. MRI is considered superior to CT for local staging. Contrast enhanced MRI imaging improves accuracy in detecting myometrial invasion.

Case 4

CT has a role in assessing for distant metastases. Case 4

acsearch.acr.org/docs/69458/Narrative

Case 5 PRE or Post menopausal bleeding per vaginum First study? US pelvis trans vaginal US pelvis trans abdominal MR pelvis without contrast MR pelvis with/without contrast TC pelvis without contrast TC pelvis with/without contrast

Case 5

Cervical lip and endocervical canal are not distinctly identified. There is presence of a homogeneous solid mass lesion replacing cervix. It shows vascularity. Case 5

insertion Images demonstrate a locally advanced cervical cancer (stage IV) involving anterior lower rectum with tumour approaching the urethra but without definite urethral invasion. Case 5

acsearch.acr.org/docs/69461/Narrative/

Case 6 Patient with pelvic palpable mass and right pelvic pain 36 years old Increaseing CA125. Disturbed menstrual cycle

First study? US pelvis trans vaginal US pelvis trans abdominal MR pelvis without contrast MR pelvis with/without contrast TC pelvis without contrast TC pelvis with/without contrast Case 6

CA-125 levels: elevated in most ovarian malignancies (~80% in general): some mucinous and germ cell tumours may not secrete this marker AFP levels : elevated particularly with immature ovarian teratomas (~50% of cases) and ovarian yolk sac tumours Case 6

US - Solid - cystic mass in pelvis with vascularity. Uterus is normal. Ovaries are not seperately seen. Case 6

Large multilocular cystic mass, (18.8 x 18.8 x 8.8 cm), predominantly cystic with homogeneous fluid density, without a visible soft tissue component. Smooth, variable thickness cyst walls and septations. No obvious calcification. Associated moderate amount of free fluid noted within the abdomen. Case 6

Case 6

acsearch.acr.org/docs/69463/Narrative

Male 75 years old Nocturia Hesitancy Case 7 PROSTATE CANCER?!

Case 7 Prostate cancer is usually detected by: elevated (greater than 4 ng/dL) prostate-specific antigen (PSA); normal is 1-4 ng/dL. abnormal digital rectal examination – prostate cancer usually arises within the peripheral zone near the rectum, which is why a digital rectal exam (DRE) is a useful screening test. Clinically patients can present with: urinary symptoms, e.g. nocturia, hesitancy, urgency, terminal dribble etc... back pain

The primary indication for MRI of the prostate is in the evaluation of prostate cancer in order to determine if there is extracapsular extension. Increasingly MRI is also being used to detect and localize cancer when the PSA is persistently elevated but routine TRUS biopsy is negative.

Case 7

Case 7

Case 7

CT Not accurate at detecting in situ prostate cancer. Scans of the abdomen and pelvis are normally obtained prior to the onset of radiation therapy to identify bony landmarks for planning. In advanced disease, CT scan is the test of choice to identify enlarged pelvic and retroperitoneal lymph nodes, hydronephrosis and osteoblastic metastases. Case 7

acsearch.acr.org/docs/69371/Narrative

Case 8 20 year old male with acute scrotal pain

Case 8 testis to be enlarged, heterogeneous in echotexture, with without evidence of any blood flow

Case 9 36 years old men Fever Scrotal pain

Case 9 Orchitis is an infection of the testicle wich is frequently associated with epididymis and so called epididymo-orchitis. Usually bacteria retrogradely seed into the testis from the bladder or prostate. Ultrasound is the gold standard investigation. We can see focal or diffuse hypoechogenicity and hypervascularity, swelling and scrotal wall thickening.

Case 10 Male in early 20s with a dull ache in the left scrotum. In the suspect of varicocele…

Case 10 Dilated, tortuous veins of the left pampiniform plexus with reflux demonstrated on valsalva.

Case 10 The left testicular vein drains into the left renal vein (LRV.) Extrinsic compression of the LRV is a potential cause of backpressure leading to a left testicular varicocoele. In this casecompression of the left renal vein between the superior mesenteric artery and aorta, (nutcracker syndrome) appears to be the underlying cause.