(Ebookobgyne - Net) Diagnostic Imaging Gynecology, 2nd

Shaaban Shaaban
MENIAS • REZVANI • TUBAY

EL SAYED • WOODWARD
HC 91332-2 PC CC2014.indd 1 10/21/2014 8:29:31 AM

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Akram M. Shaaban, MBBCh
Associate Professor (Clinical)
Department of Radiology
University of Utah School of Medicine
Salt Lake City, Utah
Christine O. Menias, MD Marc S. Tubay, MD

Professor of Radiology Chief of Cross Sectional Imaging
Mayo Clinic School of Medicine Department of Radiology
Scottsdale, Arizona United States Air Force Academy Medical Clinic
Adjunct Professor of Radiology Colorado Springs, Colorado
Washington University School of Medicine
St. Louis, Missouri
Maryam Rezvani, MD Rania Farouk El Sayed, MD, PhD

Associate Professor of Radiology Lecturer of Radiodiagnosis
Department of Radiology Department of Radiology
University of Utah School of Medicine University of Cairo
Salt Lake City, Utah Faculty of Medicine
Cairo, Egypt
Paula J. Woodward, MD
David G. Bragg, MD and Marcia R. Bragg Presidential
Endowed Chair in Oncologic Imaging
Department of Obstetrics and Gynecology
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1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
DIAGNOSTIC IMAGING: GYNECOLOGY, SECOND EDITION ISBN: 978-1-931884-77-8
Copyright © 2015 by Elsevier. All rights reserved.
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This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be
noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices,
or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described
herein. In using such information or methods they should be mindful of their own safety
and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer
of each product to be administered, to verify the recommended dose or formula, the
method and duration of administration, and contraindications. It is the responsibility of
practitioners, relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to
take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
editors, assume any liability for any injury and/or damage to persons or property as a matter
of products liability, negligence or otherwise, or from any use or operation of any methods,
products, instructions, or ideas contained in the material herein.
Publisher Cataloging-in-Publication Data
Diagnostic imaging. Gynecology / [edited by] Akram M. Shaaban.

2nd edition.
pages ; cm
Gynecology
Includes bibliographical references and index.
ISBN 978-1-931884-77-8 (hardback)
1. Generative organs, Female--Imaging--Handbooks, manuals, etc.
I. Shaaban, Akram M. IV. Title: Gynecology.
[DNLM: 1. Genital Diseases, Female--diagnosis--Handbooks.
2. Diagnostic Imaging--Handbooks. 3. Genitalia, Female--patholgoy--Handbooks.
WP 39]
RG107.5.I4 D53 2014
618.1075--dc23
International Standard Book Number: 978-1-931884-77-8

Cover Designer: Tom M. Olson, BA
Cover Art: Lane R. Bennion, MS
Printed in Canada by Friesens, Altona, Manitoba, Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
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Dedications
To my parents, who taught me the value of perseverance & hard work.
To my wife Inji, my son Karim, and my daughters May and Jena, the
jewels of my life, thanks for your understanding & tremendous support.
To all my residents and fellows, whose challenging questions made me
a better radiologist.
AMS
I’d like to dedicate this book to all my former residents, fellows,

colleagues, and teachers, who continue to donate to the “Cooky Jar,”
and continue to teach me. It has truly been a privilege. This work could
not have been completed without them.
COM
To my parents, Houshmand & Shahla, and my sister, Sara, who humble
me with their patience and selfless support of all my endeavors. To my
aunt, Laghaieh, whose generous spirit and devotion to radiology have
always served as an example for which I continue to strive.
MR
I wish to dedicate this to my teachers and mentors, for their generosity

and dedication; to Roman and Ivy, for their endless energy and love;
and most of all to Amy, for her guidance, patience, and devotion.
MST
Thanks to my professors and colleagues in radiology and the ESUR Society,
for their inestimable support. A special dedication to my passed Prof. Hazem
Moharram & my doctoral students for their extensive effort. A special thanks
to these stars who have lit my life path—my wonderful parents, loving sisters
and brothers, children, Omar and Mariam Emad, and my kind husband, for
their endless love and support; and to Professors Suaad Moussa & Tahany
El Zainy, and Katharine O’Moore-Klopf; my friends Dr. Karen Kinkel, Tarek
ElShayal & Inas Aref. And sincere appreciation to the Amirsys team for their
guidance & making my chapters come to life.
RFES
To the awesome Amirsys pub team (Andrea, Angie, Arthur, Ashley,

Chuck, Dave, Jeff, Katherine, Kellie, Lane, Laura, Lisa, Nina, Rebecca,
Rich, Sarah, Tricia), your standard of excellence is unparalleled. I get
to be the person out front, but we all know who does the heavy lifting.
You guys rock!
PJW
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Contributing Authors Continued
Oguz Akin, MD Nyree Griffin, MD, FRCR

Associate Professor of Radiology Consultant Radiologist
Department of Radiology Guy’s and St. Thomas’ NHS Foundation Trust
Memorial Sloan-Ketteting Cancer Center London, United Kingdom
New York, New York
Winnie Hahn, MD
Sandra J. Allison, MD Staff Radiologist
Washington Radiology Associates, P.C. Department of Radiology
Associate Professor of Radiology Washington, DC Veterans Administration Medical Center
Georgetown University School of Medicine Washington, District of Columbia
Washington, District of Columbia
Olga Hatsiopoulou, MD, FRCR

Susan M. Ascher, MD, FISMRM, FSCBT/MR Consultant Radiologist
Professor of Radiology and Co-Director of Royal Hallamshire Hospital
Abdominal Imaging Sheffield Teaching Hospitals NHS Foundation Trust
Georgetown University School of Medicine Sheffield, United Kingdom
Washington, District of Columbia
Marcia C. Javitt, MD, FACR

Mostafa Atri, MD, FRCPC, Dipl. Epid. Director of Medical Imaging
Director of Ultrasound, Joint Department of Rambam Healthcare Campus
Medical Imaging (UHN, MSH, WCH)
Professor of Radiology
Professor of Radiology Technion Faculty of Medicine
University of Toronto Haifa, Israel
Toronto, Ontario, Canada
Ilse Castro-Aragon, MD Deborah Levine, MD, FACR

Professor of Radiology
Assistant Professor of Radiology
Vice-Chair of Academic Affairs
Boston University School of Medicine
Boston, Massachusetts
Director of Ob/Gyn Ultrasound

Beth Israel Deaconess Medical Center
Boston, Massachusetts
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Patricia Noël, MD, FRCPC
Professor of Radiology, Laval University
Department of Medical Imaging
CHU de Québec, I’Hôtel-Dieu de Québec
Québec, Québec, Canada
Khashayar Rafatzand, MD, FRCPC

Assistant Professor of Radiology
University of Massachusetts Medical School
Worcester, Massachusetts
Caroline Reinhold, MD, MSc

Professor of Radiology, Gynecology and Internal Medicine
(Gastroenterology)
Vice-Chair of Research
McGill University Health Center
Montreal, Québec, Canada
Evis Sala, MD, PhD

Chief of Body Imaging Service
Memorial Sloan-Kettering Cancer Center
New York, New York
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Preface
We are pleased to present Diagnostic Diagnostic Imaging: Gynecology, second edition

Imaging: Gynecology, second edition, the most maintains the signature Amirsys format of concise
extensive book of imaging in gynecologic bulleted text, Key Facts boxes, and plentiful, high-
diseases. More than 2,500 carefully annotated quality images. The online version includes another
images illustrate pertinent pathologic entities 900 images, plus additional diagnostic tips and
and demonstrate the correlation between references. In all, the book remains extremely useful
ultrasound (including 3D), sonohysterography, for radiologists and gynecologists alike, both those
hysterosalpingography, MR, PET/CT, and gross practicing and those still in training.
pathology. For ease of reference and learning,
diagnoses are grouped according to the organ
involved—uterus, cervix, vagina and vulva, I would like to thank all the editors and contributing
ovary, fallopian tubes, multiple organs, and authors from the bottom of my heart for their effort
the pelvic floor—and include all pertinent and dedication. We are extremely proud of the
pathologic entities, including congenital final product and hope that readers will appreciate
anomalies, infectious/inflammatory diseases, the effort required to produce such an amazing
and benign and malignant neoplasms. reference.
This reference builds upon the success of I also want to acknowledge the sonographers and
the first edition with new image galleries, the CT and MR technologists for their fine work,
completely revised text, and updated which is used extensively throughout this text.
references. In addition, we include a dedicated Thanks also to the amazing Amirsys staff, especially
section on techniques, designed to help Angie, Katherine, Kellie, and Jeff—whose attention
optimize imaging protocols and enhance to detail makes everything we do better—and to
diagnostic specificity. Each section now begins the illustrators—Lane, Rich, and Laura—who have
with a review of normal anatomy and variants, helped make this book truly special.
including extensive illustrations. As applicable,
we have added modules on tumor staging that
We think you’ll find this new volume a wonderfully
feature quick-reference tables, illustrations,
rich resource that will enhance your practice and find
and case examples of TNM classification,
a welcome place on your bookshelf.
FIGO staging, and AJCC prognostic groups.
The book closes with a section devoted to
the pelvic floor, the evaluation of which has
become an integral part of our clinical practice
in the last decade.
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Associate Professor (Clinical)
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Acknowledgements
Text Editing
Dave L. Chance, MA, ELS
Arthur G. Gelsinger, MA
Sarah J. Connor, BA
Tricia L. Cannon, BA
Image Editing
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS
Medical Editing
Jaclyn Taylor, MD
Marc S. Tubay, MD
Illustrations
Lane R. Bennion, MS
Laura C. Sesto, MA
Richard Coombs, MS
Art Direction and Design

Laura C. Sesto, MA
Tom M. Olson, BA
Lead Editor
Angela M. Green Terry, BA
Publishing Leads
Katherine L. Riser, MA
Rebecca L. Hutchinson, BA
Names you know. Content you trust.®
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Sections
SECTION 1: Techniques
SECTION 2: Uterus
SECTION 3: Cervix
SECTION 4: Vagina and Vulva
SECTION 5: Ovary
SECTION 6: Fallopian Tubes
SECTION 7: Multiorgan Disorders
SECTION 8: Pelvic Floor
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Septate Uterus 2-42
SECTION 1 Akram M. Shaaban, MBBCh & Susan M. Ascher, MD,
FISMRM, FSCBT/MR
Techniques
Arcuate Uterus 2-48
Akram M. Shaaban, MBBCh & Nyree Griffin, MD, FRCR &
Pelvis Evis Sala, MD, PhD
DES Exposure 2-50
Ultrasound Technique and Anatomy 1-2 Akram M. Shaaban, MBBCh & Nyree Griffin, MD, FRCR &
Marc S. Tubay, MD
Evis Sala, MD, PhD
Hysterosalpingography 1-8
Marc S. Tubay, MD
Congenital Uterine Cysts 2-52
Sonohysterography 1-16
CT Technique and Anatomy 1-18
Inflammation/Infection
Marc S. Tubay, MD Asherman Syndrome, Endometrial Synechiae 2-54
Christine O. Menias, MD & Ilse Castro-Aragon, MD &
MR Technique and Anatomy 1-22
Sandra J. Allison, MD
Marc S. Tubay, MD
Endometritis 2-58
PET/CT Technique and Imaging Issues 1-28
Christine O. Menias, MD & Ilse Castro-Aragon, MD
Marc S. Tubay, MD
Pyomyoma 2-62
Christine O. Menias, MD & Susan M. Ascher, MD, FISMRM,
SECTION 2 FSCBT/MR
Uterus Benign Neoplasms

Myometrium
Introduction and Overview Uterine Leiomyoma 2-66
Uterine Anatomy 2-2 Maryam Rezvani, MD
Marc S. Tubay, MD
Degenerated Leiomyoma 2-72
Marc S. Tubay, MD
Age-Related Changes Parasitic Leiomyoma 2-80
Akram M. Shaaban, MBBCh & Marcia C. Javitt, MD, FACR
Endometrial Atrophy 2-14
& Shephard S. Kosut, MD
Maryam Rezvani, MD & Sandra J. Allison, MD
Benign Metastasizing Leiomyoma 2-84
Akram M. Shaaban, MBBCh & Winnie Hahn, MD
Congenital Diffuse Leiomyomatosis 2-86
Introduction to Müllerian Duct Anomalies 2-16 Christine O. Menias, MD & Oguz Akin, MD
Intravenous Leiomyomatosis 2-90
Uterine Hypoplasia/Agenesis 2-20 Christine O. Menias, MD & Ilse Castro-Aragon, MD
Disseminated Peritoneal Leiomyomatosis 2-94
Christine O. Menias, MD & Ilse Castro-Aragon, MD &
Unicornuate Uterus 2-26 Deborah Levine, MD, FACR
Lipomatous Uterine Tumors 2-96
Christine O. Menias, MD & Patricia Noël, MD, FRCPC &
Uterus Didelphys 2-32 Caroline Reinhold, MD, MSc
Caroline Reinhold, MD, MSc Endometrium
Endometrial Polyps 2-100
Bicornuate 2-38 Maryam Rezvani, MD
Akram M. Shaaban, MBBCh & Caroline Reinhold, MD, MSc
& Khashayar Rafatzand, MD, FRCPC Endometrial Hyperplasia 2-106
Maryam Rezvani, MD
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Malignant Neoplasms Malignant Neoplasms
Myometrium Cervical Carcinoma 3-20
Maryam Rezvani, MD
Adenosarcoma 2-110
Christine O. Menias, MD & Evis Sala, MD, PhD Adenoma Malignum 3-50
Christine O. Menias, MD & Oguz Akin, MD
Malignant Mixed Mesodermal Tumor 2-114
Christine O. Menias, MD & Oguz Akin, MD Cervical Sarcoma 3-54
Christine O. Menias, MD & Nyree Griffin, MD, FRCR & Evis
Uterine Leiomyosarcoma 2-120
Sala, MD, PhD
Christine O. Menias, MD & Oguz Akin, MD
Cervical Melanoma 3-58
Endometrium Akram M. Shaaban, MBBCh & Nyree Griffin, MD, FRCR &
Endometrial Carcinoma 2-124 Evis Sala, MD, PhD
Maryam Rezvani, MD & Sandra J. Allison, MD
Endometrial Stromal Sarcoma 2-142 Treatment-Related Conditions
Christine O. Menias, MD & Caroline Reinhold, MD, MSc &
Khashayar Rafatzand, MD, FRCPC Post-Trachelectomy Appearances 3-62
Maryam Rezvani, MD
Gestational Trophoblastic Disease 2-146
Miscellaneous
Vascular Cervical Glandular Hyperplasia 3-64
Maryam Rezvani, MD
Uterine Arteriovenous Malformation 2-162
Maryam Rezvani, MD Nabothian Cysts 3-68
Maryam Rezvani, MD
Uterine Artery Embolization Imaging 2-168
Maryam Rezvani, MD
SECTION 4
Treatment-Related Conditions
Tamoxifen-Induced Changes 2-174
Vagina and Vulva
Maryam Rezvani, MD
Contraceptive Device Evaluation 2-180 Introduction and Overview
Maryam Rezvani, MD
Vaginal and Vulvar Anatomy 4-2
Post Cesarean Section Appearance 2-188 Marc S. Tubay, MD
Maryam Rezvani, MD
Congenital
Adenomyosis Vaginal Atresia 4-10
Adenomyosis 2-192 Christine O. Menias, MD & Caroline Reinhold, MD, MSc
Maryam Rezvani, MD
Imperforate Hymen 4-14
Adenomyoma 2-198 Christine O. Menias, MD & Caroline Reinhold, MD, MSc
Maryam Rezvani, MD
Vaginal Septa 4-16
Cystic Adenomyosis 2-202 Christine O. Menias, MD & Caroline Reinhold, MD, MSc
Maryam Rezvani, MD
Benign Neoplasms
SECTION 3 Vaginal Leiomyoma 4-18
Akram M. Shaaban, MBBCh & Olga Hatsiopoulou, MD,
Cervix FRCR & Evis Sala, MD, PhD
Vulvar Hemangioma 4-24
Introduction and Overview Christine O. Menias, MD & Oguz Akin, MD
Cervical Anatomy 3-2 Vaginal Paraganglioma 4-28

Marc S. Tubay, MD Christine O. Menias, MD
Infection/Inflammation Malignant Neoplasms

Cervical Stenosis 3-8 Vaginal Carcinoma 4-32
Christine O. Menias, MD & Sandra J. Allison, MD Akram M. Shaaban, MBBCh
Vaginal Leiomyosarcoma 4-44
Benign Neoplasms FRCR & Evis Sala, MD, PhD
Endocervical Polyp 3-12 Embryonal Rhabdomyosarcoma 4-46
Christine O. Menias, MD & Sandra J. Allison, MD Christine O. Menias, MD
Cervical Leiomyoma 3-16
Christine O. Menias, MD & Sandra J. Allison, MD
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Vaginal Yolk Sac Tumor 4-50 Neoplasms
FRCR & Evis Sala, MD, PhD Ovarian Carcinoma Overview 5-40
Bartholin Gland Carcinoma 4-54
Christine O. Menias, MD & Olga Hatsiopoulou, MD, FRCR & Epithelial
Evis Sala, MD, PhD
Serous Cystadenoma 5-62
Vulvar Carcinoma 4-56 Akram M. Shaaban, MBBCh & Marcia C. Javitt, MD, FACR
Maryam Rezvani, MD & Shephard S. Kosut, MD
Vulvar Leiomyosarcoma 4-70 Mucinous Cystadenoma 5-68
Christine O. Menias, MD & Nyree Griffin, MD, FRCR & Evis Akram M. Shaaban, MBBCh & Winnie Hahn, MD &
Sala, MD, PhD Deborah Levine, MD, FACR
Vulvar and Vaginal Melanoma 4-72 Adenofibroma and Cystadenofibroma 5-74
Akram M. Shaaban, MBBCh & Evis Sala, MD, PhD Akram M. Shaaban, MBBCh & Ilse Castro-Aragon, MD &
Sandra J. Allison, MD
Aggressive Angiomyxoma 4-76
Christine O. Menias, MD & Evis Sala, MD, PhD & Jo Hugil, Ovarian Serous Carcinoma 5-80
MD Akram M. Shaaban, MBBCh & Oguz Akin, MD
Merkel Cell Tumor 4-80 Mucinous Cystadenocarcinoma 5-86
Christine O. Menias, MD & Oguz Akin, MD Akram M. Shaaban, MBBCh & Oguz Akin, MD & Deborah
Levine, MD, FACR
Lower Genital Cysts Ovarian Endometrioid Carcinoma

5-92
Gartner Duct Cysts 4-82

Marc S. Tubay, MD
Ovarian Clear Cell Carcinoma 5-98
Akram M. Shaaban, MBBCh & Oguz Akin, MD
Bartholin Cysts 4-86
Marc S. Tubay, MD
Carcinosarcoma (Ovarian Mixed Müllerian 5-104
Tumor)
Bartholinitis 4-90 Akram M. Shaaban, MBBCh & Evis Sala, MD, PhD
Marc S. Tubay, MD
Ovarian Transitional Cell Carcinoma 5-108
Urethral Diverticulum 4-94 Akram M. Shaaban, MBBCh
Marc S. Tubay, MD
Germ Cell
Skene Gland Cyst 4-98
Marc S. Tubay, MD Dermoid (Mature Teratoma) 5-114
Akram M. Shaaban, MBBCh & Sandra J. Allison, MD &
Deborah Levine, MD, FACR
Miscellaneous Immature Teratoma 5-124
Akram M. Shaaban, MBBCh & Evis Sala, MD, PhD
Vaginal Foreign Bodies 4-102
Christine O. Menias, MD & Olga Hatsiopoulou, MD, FRCR Dysgerminoma 5-128
& Evis Sala, MD, PhD Akram M. Shaaban, MBBCh & Oguz Akin, MD
Vaginal Fistula 4-110 Ovarian Yolk Sac Tumor 5-132
Marc S. Tubay, MD Akram M. Shaaban, MBBCh & Evis Sala, MD, PhD
Ovarian Choriocarcinoma 5-136
Akram M. Shaaban, MBBCh & Evis Sala, MD, PhD
SECTION 5
Ovarian Carcinoid 5-140
Ovary Akram M. Shaaban, MBBCh & Evis Sala, MD, PhD
Ovarian Mixed Germ Cell Tumor, Embryonal 5-144
Carcinoma and Polyembryoma
Introduction and Overview Akram M. Shaaban, MBBCh
Ovarian Anatomy 5-2 Struma Ovarii 5-148
Marc S. Tubay, MD Akram M. Shaaban, MBBCh
Sex Cord-Stromal
Physiologic and Age-Related Changes Granulosa Cell Tumor 5-154
Follicular Cyst 5-12 Akram M. Shaaban, MBBCh & Ilse Castro-Aragon, MD
Marc S. Tubay, MD Fibroma, Thecoma, and Fibrothecoma 5-160
Corpus Luteal Cyst 5-18 Akram M. Shaaban, MBBCh & Mostafa Atri, MD, FRCPC,
Marc S. Tubay, MD Dipl Epid & Caroline Reinhold, MD, MSc
Theca Lutein Cysts 5-24 Sertoli-Stromal Cell Tumors 5-166

Akram M. Shaaban, MBBCh & Patricia Noël, MD, FRCPC & Akram M. Shaaban, MBBCh
Caroline Reinhold, MD, MSc Sclerosing Stromal Tumor 5-172
Hemorrhagic Ovarian Cyst 5-28 Akram M. Shaaban, MBBCh & Evis Sala, MD, PhD
Paula J. Woodward, MD Metastases and Hematological
Ovarian Inclusion Cyst 5-34 Ovarian Metastases 5-176
Marc S. Tubay, MD Akram M. Shaaban, MBBCh & Oguz Akin, MD
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Ovarian Lymphoma 5-182 Miscellaneous
Akram M. Shaaban, MBBCh & Oguz Akin, MD
Hematosalpinx 6-54
Maryam Rezvani, MD
Nonneoplastic Ovarian Lesions
Endometrioma 5-188
Maryam Rezvani, MD SECTION 7
Endometriosis
Maryam Rezvani, MD
5-198 Multiorgan Disorders
Ovarian Hyperstimulation Syndrome 5-208
Marc S. Tubay, MD Malignant Neoplasms
Polycystic Ovary Syndrome 5-212 Genital Lymphoma 7-2
Maryam Rezvani, MD Christine O. Menias, MD
Peritoneal Inclusion Cysts 5-218 Genital Metastases 7-8
Marc S. Tubay, MD Christine O. Menias, MD
Vascular Abnormal Sexual Development

Ovarian Vein Thrombosis 5-226 Androgen Insensitivity Syndrome 7-14
Marc S. Tubay, MD Christine O. Menias, MD & Caroline Reinhold, MD, MSc &
Pelvic Congestion Syndrome 5-232
Christine O. Menias, MD & Susan M. Ascher, MD, Ambiguous Genitalia 7-16
FISMRM, FSCBT/MR Christine O. Menias, MD & Tamar Sella, MD
Acute Adnexal Torsion 5-236 Gonadal Dysgenesis 7-20
Akram M. Shaaban, MBBCh Christine O. Menias, MD & Caroline Reinhold, MD, MSc &
Massive Ovarian Edema and Fibromatosis 5-242
SECTION 8
SECTION 6 Pelvic Floor
Fallopian Tubes
Overview
Congenital Overview of the Pelvic Floor 8-2
Rania Farouk El Sayed, MD, PhD
Paratubal Cyst 6-2
Maryam Rezvani, MD Pelvic Floor Imaging 8-30
Pelvic Inflammatory Disease, General Considerations 6-6
Pelvic Floor Dysfunction
Paula J. Woodward, MD Anterior Compartment
Hydrosalpinx 6-10 Overview of the Anterior Compartment 8-40
Pyosalpinx 6-14 Anterior Compartment Imaging 8-60
Tubo-Ovarian Abscess 6-18 Middle Compartment
Maryam Rezvani, MD
Overview of the Middle Compartment 8-68
Genital Tuberculosis 6-22 Rania Farouk El Sayed, MD, PhD
Maryam Rezvani, MD
Middle Compartment Imaging 8-80
Actinomycosis 6-26 Rania Farouk El Sayed, MD, PhD
Maryam Rezvani, MD
Posterior Compartment
Salpingitis Isthmica Nodosa 6-30 Overview of the Posterior Compartment 8-88
Paula J. Woodward, MD Rania Farouk El Sayed, MD, PhD
Imaging of Fecal Incontinence 8-102
Benign Neoplasms Rania Farouk El Sayed, MD, PhD
Tubal Leiomyoma 6-34 Imaging of Obstructed Defecation 8-112

Multicompartmental
Malignant Neoplasms Multicompartmental Imaging 8-126
Fallopian Tube Carcinoma 6-38
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SECTION 1
Techniques
Pelvis
Ultrasound Technique and Anatomy 1-2
Hysterosalpingography 1-8
Sonohysterography 1-16
CT Technique and Anatomy 1-18
MR Technique and Anatomy 1-22
PET/CT Technique and Imaging Issues 1-28
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ULTRASOUND TECHNIQUE AND ANATOMY
Techniques
Longitudinal transabdominal US image shows an IUD Longitudinal transvaginal ultrasound shows a normal
within an otherwise normal-appearing uterus . ovary with a few follicles . The ovaries should be
Transabdominal US should be performed with a full measured in 3 orthogonal planes and carefully evaluated
bladder to provide an adequate imaging window. for suspicious masses.
• Doppler ultrasound uses frequency shifts of reflected

TERMINOLOGY sound waves to detect flowing blood
Abbreviations ◦ Blood flow can be evaluated with
• ▪ Color Doppler: Flow is assigned a color based on
Transabdominal sonography (TAS)
• Transvaginal ultrasound (TVUS) direction of flow and overlaid on B-mode images
• ▪ Power Doppler: Measures intensity of Doppler shift
Endovaginal (EV)
• Saline-infused sonohysterogram (SIS) overlaid on a grayscale image; more sensitive for
• Peak systolic velocity (PSV) detection of slow flow
• ▪ Pulsed-wave (spectral) Doppler: Velocity tracing
End diastolic velocity (EDV)
is generated, allowing for velocity and waveform
Definitions analysis
• Ultrasound is an imaging modality that transmits - Duplex Doppler: Pulsed-wave Doppler displayed
high frequency sound waves into tissues and generates with grayscale anatomic images
images from reflected waves - Triplex Doppler: Pulsed-wave Doppler displayed
◦ TAS provides a large field of view with grayscale images overlaid with color
▪ Lower frequencies are used to allow for a greater Doppler
depth of view ◦ Presence of central blood flow can help distinguish a
- Results in lower resolution images solid mass from a complicated cystic lesion
▪ Useful for large masses ◦ Vascularized nodules or thickened septations may
▪ Use for superficial lesions and lesions out of range increase suspicion of malignancy for a particular
of vaginal probe lesion
▪ Mid to late gestations are generally better evaluated ◦ Resistive index: (PSV-EDV)/PSV
with TAS ▪ Low resistive index (< 0.4) is associated with
◦ TVUS gives higher resolution images of uterus, malignancy but can also be seen in benign lesions
cervix, and adnexa with high flow (corpus luteum, metabolically
▪ Higher frequencies allow for higher resolution active benign mass, inflammation)
images at expense of decreased depth of view ▪ High resistive index (> 0.7) associated with benign
▪ Field of view is more constrained lesions, though not diagnostic
▪ Key technique in evaluation of uterine, cervical, ▪ Thoroughly evaluate entirety of mass, as velocities
and adnexal pathology can differ between solid components
▪ Useful in evaluation of early pregnancy • 3D ultrasound
• B-mode (grayscale, 2D mode) ultrasound ◦ Acquires a volume of ultrasound data
◦ Reflected sound wave data is reconstructed to ◦ Volume can be manipulated at US machine or at
produce 2D grayscale image of a plane of tissue dedicated workstation to produce multiplanar images
◦ Majority of ultrasound examinations are performed or 3D reconstructions
using B-mode ◦ Can provide images of similar orientation and quality
• M-mode ultrasound to MR
◦ Column of tissue perpendicular to probe is • 4D ultrasound: 3D US data is acquired continuously
interrogated to evaluate for motion/velocity over time
◦ In pelvic sonography, used almost exclusively to ◦ Allows generation of 3D sonographic movies
1 demonstrate embryonic/fetal cardiac activity and

obtain heart rate
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Key Facts
Terminology ◦ Transperineal, translabial, and transrectal
• Ultrasound is an imaging modality that transmits approaches are less frequently used
high frequency sound waves into tissues and generates • TVUS gives higher resolution images of uterus, cervix,
images from reflected waves and adnexa
• Pelvic sonography can be performed using a number • Pelvic ultrasound requires dedicated evaluation and
of techniques (M-mode, 2D, Doppler, 3D, 4D) reporting of
◦ Uterus: Size, contour, positioning, myometrial
Pre-Procedure echotexture/masses
• Transabdominal US is usually performed with a full ◦ Endometrium: Thickness, appearance, presence/
bladder positioning of IUD
• Transvaginal pelvic US is performed with an empty ◦ Adnexa: Ovarian size, presence of cystic/solid mass,
bladder ovarian vascular flow, tubal abnormalities
◦ Cul-de-sac: Presence of fluid or mass
Procedure • Probes must be thoroughly cleansed according to
• Most pelvic sonographic examinations are performed manufacturer's and local institution's guidelines
with a combined transabdominal and transvaginal
technique
▪ 100 mW/cm² is intensity below which no

PRE-PROCEDURE significant biologic effects in mammalian tissues in
Indications vivo
• ▪ Thermal index < 2 and mechanical index < 0.3 are
Common indications for pelvic sonography include
pelvic pain, mass, abnormal/dysfunctional vaginal safe levels for routine use
◦ Commercial probe cover or condom to cover EV
bleeding, staging for cancer
probe for TVUS
Contraindications ▪ If latex allergy, do not use latex probe covers
• TAS can be uncomfortable due to full bladder ◦ Dedicated EV probe cleaning system and solution
• TVUS should be avoided in patients with an intact ◦ US gel
hymen or prior to having had intercourse
◦ Transperineal/translabial sonography can be PROCEDURE
performed when needed
◦ Patients may decline study due to being Patient Position/Location
uncomfortable with procedure • Best procedure approach
◦ Positioning for TAS
Getting Started ▪ Patient comfortably positioned in supine position
• Things to check ◦ Positioning for TVUS
◦ Full bladder for TAS ▪ Patient in lithotomy position, feet in stirrups if bed
▪ Full bladder acts as an acoustic window and helps
is so equipped
to better evaluate uterus/adnexa ▪ Pillow under buttocks can be utilized if needed,
▪ Pushes small bowel from field of view
especially if bed does not have stirrups
▪ Overfilled bladder may push uterus and ovaries ▪ Similar positioning for translabial or transperineal
away from probe, making evaluation more difficult examinations
◦ Empty bladder for TVUS • In many centers, routine pelvic ultrasound
▪ Describe use of transvaginal probe to patient
examinations include both TAS and TVUS
▪ Many sonographers prefer to have patient insert EV ◦ Patient undergoes TAS with full bladder
probe herself ◦ After voiding, patient undergoes TVUS
▪ Only a portion of probe is inserted • Some centers may not routinely perform both TAS and
▪ Exam should be relatively painless
TVUS for each patient
▪ If bladder is too distended, it may push uterus and ◦ Perform EV examination initially, and only perform
ovaries out of field of view TAS if TVUS is insufficient
◦ In women of childbearing age, knowledge of serum β- ◦ Some centers begin with TAS but do not make patient
hCG levels may be useful fill bladder
• Equipment list ▪ Limited TAS to assess uterine size, large masses
◦ Ultrasound machine ▪ Proceed to TVUS
◦ Appropriate transducers ▪ Repeat TAS with full bladder only in cases when
▪ 3.5-7 MHz for transabdominal scans (curved or
TVUS insufficient
sector) • Transperineal/translabial evaluations
▪ 5-12 MHz for EV scans (dedicated EV probe) ◦ Utilized for visualization of labial/vulvar, distal
▪ 7-15 MHz for superficial translabial/transperineal
urethral, and vaginal anomalies
scans (linear probe) ◦ Use a sector or linear transducer covered with
◦ Safety issues
condom or commercially available probe cover
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◦ Utilized for assessment of primary amenorrhea in - Alternatively, locate iliac vasculature in

patients with intact hymen longitudinal plane and slowly image toward
◦ Useful in evaluation of cervix and lower uterus midline
in late-term pregnant patients for whom TVUS is ▪ Gentle pressure on anterior abdominal wall can
contraindicated move bowel gas out of the way to improve ovarian
• Transrectal US may be useful to evaluate anal sphincter visualization
in setting of pelvic floor dysfunction ▪ Ovaries should be measured in 3 orthogonal planes
▪ Obtain color and duplex Doppler images of ovaries,
Equipment Preparation documenting arterial and venous waveforms
• Probes need to be meticulously cleansed according to ▪ Measure largest cyst/follicle &/or any atypical
manufacturer's and local institutional guidelines appearing adnexal lesion in 3 planes
• Rinse probes prior to use to avoid chemical irritation ▪ Determine if cyst/mass arises from ovary or is
from disinfectants separate from ovary
• US gel is better tolerated by patient if warmed - Gently press with EV probe; adnexal mass
Procedure Steps arising from ovary will move with ovary whereas
• TAS and TVUS examinations should include paraovarian mass will move independent from
◦ Uterine imaging ovary with pressure
▪ Uterine length measurements - Imaging as pressure is applied to anterior
- Measure uterine length in sagittal midline image abdominal wall may also help distinguish
(long axis of uterus) from fundus to external exophytic ovarian mass from paraovarian mass
▪ Doppler can be helpful to distinguish between
cervical os
- Uterine depth/AP measurement is measured parametrial vessel and adnexal cyst
▪ Doppler can be helpful to determine if lesion is
on same sagittal long axis image of uterus,
perpendicular to length measurement solid (increasing likelihood of malignancy) or is a
- Uterine width is measured on axial/coronal complicated cyst (hemorrhagic)
▪ Bladder filling &/or emptying can help determine
image of uterus
▪ Cervical images etiology and location of a pelvic cyst in cases where
- Transverse and longitudinal images through large cyst is mistaken for urinary bladder
◦ Scan between uterus and ovaries to assess for other
cervix
▪ Representative images of myometrium adnexal masses
- Several long (parasagittal) and transverse images ▪ May identify paraovarian cysts/masses or dilated
through entire uterus fallopian tube

▪ Myometrial masses should be documented ▪ 3D US can help confirm tubular nature of
- Measure 2 largest leiomyomas/masses in 3 planes suspected hydrosalpinx
- Measure exophytic masses in 3 planes ▪ Of particular importance in cases of suspected
- Usually not necessary to measure all masses ectopic pregnancy
▪ In setting of prior hysterectomy, evaluation of ◦ Evaluate for fluid or mass in cul-de-sac
◦ In patients with focal tenderness or pain, area of
vaginal cuff should be performed
◦ Endometrial evaluation maximal pain should be thoroughly evaluated
▪ Measure endometrial thickness perpendicular to • In cases of pelvic masses, TAS may also include
long axis of uterus on midline sagittal image evaluation of kidneys for hydronephrosis/hydroureter
▪ Include both layers of endometrium • For TVUS evaluation, EV probe should be slowly and
- If there is fluid within endometrial cavity, gently inserted
◦ As probe is being inserted, images should be assessed
it should be excluded by measuring each
endometrial layer separately for vaginal wall masses
▪ Exclude hypoechoic subendometrial zone in ◦ Scan generally performed through anterior vaginal
endometrial measurement wall, with probe positioned in anterior fornix

▪ Document and measure focal endometrial ◦ If uterus is retroverted or retroflexed, scan may be
thickening or masses performed through posterior vaginal wall

- If focal endometrial lesion, color and pulsed ◦ Angle probe gently to avoid pain
◦ Some patients have pain when cervix is manipulated,
Doppler may be helpful to help evaluate for a
vascular stalk so avoid excess probe pressure on cervix
- Any endometrial cystic change should be imaged ◦ In patients with bowel gas obscuring visualization of
▪ If an IUD is present, dedicated imaging in ovary, gentle abdominal pressure can displace bowel
longitudinal and transverse planes should be loops and allow for visualization of ovary
• Transperineal evaluation
obtained
- Acquisition of a 3D volume, with coronal ◦ Sagittal midline views of vagina, cervix, and lower
reformatted image, is very useful in evaluation of uterus are obtained

◦ Parasagittal views as indicated
IUD embedment or expulsion
◦ Adnexal imaging ◦ If performed during pregnancy
▪ If ovaries are difficult to find, obtain a coronal view ▪ Relationship between internal cervical os and
of uterine fundus and angle laterally to region of placental margin should be evaluated
▪ Measure cervix and assess for funneling
broad ligament
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• Transrectal pelvic sonography is occasionally helpful, • If scanning is performed for infertility, water or saline
though rarely performed may be used as a lubricant to avoid adverse effect on
• Saline-infused sonohysterography sperm motility
◦ Sterile saline is injected into endometrial cavity via
balloon-tipped catheter
Things to Avoid
• Male sonographers/sonologist should always have a
◦ TVUS is performed simultaneously
◦ Saline separates coapted endometrial layers, allowing female chaperone for TVUS
for visualization of polyps or focal endometrial
masses
OUTCOMES
Findings and Reporting Problems
• • Postmenopausal women with atrophic vaginitis may
Uterine size
• Uterine contour not tolerate TVUS
◦ In cases of suspected müllerian duct anomalies, ◦ Use small probe
◦ Use extra lubricating gel
3D US can depict external uterine contour to help
◦ Allow patient to insert probe herself
characterize anomaly
• Uterine positioning
◦ Version: Positioning of uterus with relation to vagina SELECTED REFERENCES
◦ Flexion: Positioning of uterine fundus in relation to
1. Armstrong L et al: Three-dimensional volumetric
cervix sonography in gynecology: an overview of clinical
• Description of myometrial echotexture applications. Radiol Clin North Am. 51(6):1035-47, 2013
• Presence of myometrial masses location and largest size 2. Sakhel K et al: Begin with the basics: role of 3-dimensional
◦ Including location, size, and position within uterine sonography as a first-line imaging technique in the
wall cost-effective evaluation of gynecologic pelvic disease. J
• Appearance of cervix Ultrasound Med. 32(3):381-8, 2013
• Endometrial thickness 3. Andreotti RF et al: Sonographic evaluation of acute pelvic
• pain. J Ultrasound Med. 31(11):1713-8, 2012
Presence of endometrial masses, fluid, cystic change,
4. Langer JE et al: Imaging of the female pelvis through the life
IUD, abnormal thickening, or areas that are ill defined cycle. Radiographics. 32(6):1575-97, 2012
or not well imaged 5. American Institute of Ultrasound in Medicine: AIUM
• Ovarian size practice guideline for the performance of pelvic ultrasound
• Presence of suspicious adnexal masses examinations. J Ultrasound Med. 29(1):166-72, 2010
◦ Ovarian cysts/follicles out of physiologic range 6. Dietz HP: Pelvic floor ultrasound: a review. Am J Obstet
◦ Complicated/complex or solid adnexal masses Gynecol. 202(4):321-34, 2010
◦ Tubal abnormalities 7. Forsberg F et al: Comparing image processing techniques for
• improved 3-dimensional ultrasound imaging. J Ultrasound
Ovarian arterial and venous waveforms detected on
Med. 29(4):615-9, 2010
duplex Doppler evaluation 8. Valsky DV et al: Three-dimensional transperineal
• Free fluid ultrasonography of the pelvic floor: improving visualization
Alternative Procedures/Therapies for new clinical applications and better functional
assessment. J Ultrasound Med. 26(10):1373-87, 2007
• Radiologic 9. Timor-Tritsch IE et al: Three-dimensional inversion
◦ MR
rendering: a new sonographic technique and its use in
▪ Provides comprehensive evaluation of pelvic gynecology. J Ultrasound Med. 24(5):681-8, 2005
anatomy 10. Bega G et al: Three-dimensional ultrasonography in
▪ Better soft tissue characterization gynecology: technical aspects and clinical applications. J
▪ Multiplanar capabilities Ultrasound Med. 22(11):1249-69, 2003
◦ CT 11. Lev-Toaff AS: Sonohysterography: evaluation of endometrial
▪ Not indicated for uterine or adnexal screening
and myometrial abnormalities. Semin Roentgenol.
31(4):288-98, 1996
▪ Useful in staging of pelvic malignancies
12. Freimanis MG et al: Transvaginal ultrasonography. Radiol
◦ Hysterosalpingography
Clin North Am. 30(5):955-76, 1992
▪ Primarily used in evaluation of tubal patency
• Surgical
◦ Blind endometrial biopsy for abnormal bleeding
◦ Hysteroscopic biopsy for focal endometrial lesions
◦ Laparoscopy
POST-PROCEDURE
Expected Outcome
• No harmful effects from pelvic sonography
• TAS and TVUS are generally well tolerated
Things to Do
• Cleanse probes according to manufacturer's and
institution's guidelines
• Must have gel both inside and outside probe cover to
prevent artifact from interposed air 1
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M-Mode US: Embryonic Cardiac Activity Power Doppler: Ovarian Mass

(Left) Longitudinal M-mode US
in a 1st trimester pregnancy
shows embryonic cardiac
activity , confirming
viability of the gestation .
M-mode is typically used in
obstetric US imaging. (Right)
Longitudinal transabdominal
ultrasound shows a large
complex cystic adnexal mass
. Power Doppler evaluation
demonstrates blood flow
within a heterogeneous mural
nodule . Color and power
Doppler can confirm flow
within internal septations and
mural nodules.
Color Doppler: Ovarian Arterial Flow Color Doppler: Ovarian Venous Flow
(Left) Transverse transvaginal
duplex Doppler evaluation
shows color flow within
the right ovary with
corresponding low-resistance
arterial waveform on
spectral analysis. Note the
normal ovarian follicle .
(Right) Transverse transvaginal
duplex Doppler evaluation
shows color flow within the
left ovary with nonpulsatile
venous waveform on
spectral analysis. In cases of
suspected torsion, it is crucial
to evaluate the ovaries for
arterial and venous waveforms.
3D US: Endometrial Polyp 3D US: IUD Positioning

(Left) Reconstructed coronal
view of the uterus from a
3D ultrasound study shows a
polypoid lesion within the
endometrial cavity outlined
by fluid. The polyp was not
visualized on 2D ultrasound
evaluation, though clearly seen
on 3D reconstructions. (Right)
Reconstructed coronal view of
the uterus (fundal contour )
from a 3D ultrasound shows
an IUD positioned within
the endometrial cavity. Uterine
embedment is better evaluated
on 3D reconstructions than 2D
studies.
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Ultrasound Probes Transvaginal US: Endometrioma
(Left) This image demonstrates
the different types of probes
used in gynecological US: 2D
EV probe , 3D endovaginal
(EV) probe , 3D curved
transabdominal (TA) probe
, 2D curved TA probe ,
2D sector probe , 2D linear
probe . (Right) Transverse
transvaginal pelvic ultrasound
image shows a multilocular
cystic adnexal mass with
homogeneous low-level internal
echoes. This persisted on serial
imaging and was proven to be an
endometrioma on MR imaging.
Transabdominal US: Abnormal

Endometrial Thickening Transvaginal US: Hydrosalpinx
(Left) Longitudinal
transabdominal ultrasound of
the pelvis shows the uterus
with a grossly thickened
endometrial echocomplex ,
proven to be malignancy in this
patient with postmenopausal
bleeding. Transabdominal
sonography can best evaluate for
uterine size and large masses.
(Right) Longitudinal transvaginal
ultrasound demonstrates a
with tubular elements. The
incomplete septations are
clues that confirm the diagnosis
of hydrosalpinx.
Transperineal US: Urethral Evaluation Superficial US: Pelvic Wall Mass

(Left) Longitudinal transperineal
ultrasound demonstrates
the normal urethra .
Transperineal/translabial US can
be used to evaluate the vagina
or urethra or when transvaginal
US is contraindicated. (Right)
Transverse ultrasound of the
superficial pelvic wall in a
patient with a palpable lesion
and cyclical pain shows an
irregular hypoechoic mass
proved to be a C-section
scar endometrioma on biopsy.
Superficial lesions are best
evaluated with high-frequency
linear probes.
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HYSTEROSALPINGOGRAPHY
Techniques
Frontal fluoroscopic image from an HSG shows the Frontal fluoroscopic image demonstrates a fixed filling
normal appearance of the uterus and fallopian tubes defect along the left aspect of the endometrial cavity.
, with free spillage on contrast into the pelvis . Note Subsequent MR showed this to be a submucosal fibroid.
the contrast reflux into the vagina .
- Most common cause remains pelvic

TERMINOLOGY inflammatory disease (PID)
Abbreviations ▪ Tubal disease
• - Hydrosalpinx
Hysterosalpingogram (HSG)
- Peritubal adhesions
Definitions - Salpingitis isthmica nodosa
• Fluoroscopic evaluation of uterine cavity and fallopian - Cornual/tubal polyps
tubes ◦ Tubal evaluation following intervention
▪ To assess patency following tubal ligation or
Advantages
•
reversal of tubal ligation
Best method to assess fallopian tube patency ▪ Confirm occlusion by tubal occlusive devices
• Relatively easy to perform
• Medications are typically not required Contraindications
• Pregnancy
Disadvantages ◦ Risks related to ionizing radiation exposure
• Invasive procedure ◦ Displacement of embryo leading to potential for
• Uses ionizing radiation
•
miscarriage
May be uncomfortable • Active PID
◦ PID or history of PID in preceding 6 months
PRE-PROCEDURE ◦ Can cause progression of infection, septicemia
Indications • Severe iodine allergy
• ◦ Extremely rare with use of currently available low-
Primary indication: Infertility
◦ Initial test in evaluation of tubal patency osmolar nonionic contrast agents
◦ Integral part of routine work-up in most centers • Relative contraindication: Active menstrual bleeding
◦ Typically performed in conjunction with pelvic ◦ May cause difficulty in interpretation
▪ Blood clots can mimic polyps or result in tubal
ultrasound
• Other indications include occlusion
◦ Recurrent spontaneous abortions ▪ Minimize by ensuring no bleeding/spotting on day
▪ Can assess for mechanical/structural causes of of study
◦ Increased risk of contrast intravasation
secondary infertility
◦ Uterine abnormalities ▪ Venous or lymphatic intravasation is clinically
▪ Müllerian duct anomalies insignificant and not dangerous
▪ Polyps
Getting Started
▪ Leiomyomas
• Things to check
▪ Adhesions/synechia (Asherman syndrome); post
◦ β-hCG
procedure or post infection/inflammatory ▪ Many centers routinely perform a serum pregnancy
▪ Adenomyosis
test to exclude pregnancy before procedure
▪ Endometrial hyperplasia
◦ Date of last menstrual cycle
◦ Tubal abnormalities
▪ Examination scheduled during days 7-12 of
▪ Tubal occlusion
menstrual cycle as endometrium is thin and
- Identify level of tubal occlusion
1 smooth, which facilitates image interpretation
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Key Facts
Terminology Procedure
• Fluoroscopic evaluation of uterine cavity and fallopian • Detailed explanation of procedure and patient
tubes reassurance are vital, followed by written consent
Pre-Procedure • Procedure involves cannulation of cervix with a
balloon-tipped catheter and injection of contrast into
• Infertility is primary indication endometrial cavity under fluoroscopy
◦ Other indications include recurrent spontaneous ◦ Fallopian tube morphology is evaluated, and
abortions, müllerian duct anomalies, uterine/ patency is confirmed with free spillage of contrast
endometrial masses, tubal abnormalities into peritoneal cavity
• Absolute contraindications include pregnancy, active
PID, iodine allergy Post-Procedure
◦ Relative contraindication: Active menstrual bleeding • Significant complications are rare; minor
• Confirmation of nonpregnant status is necessary prior complications include cramping and minimal
to procedure bleeding
• Prophylactic or postprocedural antibiotics are usually
not necessary
▪ Day 1 is defined as 1st day of menstrual bleeding - Medium sized speculum is adequate for most
▪ Patient should call to schedule on 1st day of patients
menstrual bleeding if menstrual cycle is irregular ▪ 5-French balloon-tipped HSG catheter
◦ Abstinence from sexual intercourse from time - Other catheter types are infrequently used
menstrual bleeding ends until day of study ▪ Cervical dilator (if needed)
▪ Reduces potential for early pregnancy ◦ Water-soluble, nonionic contrast medium
◦ If there is suspected PID ▪ Dedicated HSG contrast agents are available
▪ Erythrocyte sedimentation rate (ESR) may be ▪ Conventional iodinated intravenous contrast
measured to evaluate for active PID agents may be used
▪ Negative gonorrhea and chlamydia cultures ▪ Prepare at least 10 mL of contrast media, more is
are acceptable in patients with coexistent rarely necessary
inflammatory conditions (e.g., arthritis, ◦ Oil-based agents may also be used
sarcoidosis, collagen vascular disease) ▪ Higher rate of complications (oil emboli and
▪ Antibiotic prophylaxis should be considered with granuloma formation) with oil-based agents
history of prior PID
◦ Evaluate for history of severe iodine allergy or latex PROCEDURE
allergy
• Medications Patient Position/Location
◦ Patient advised to take over-the-counter NSAID pain • Best procedure approach
◦ Cervical cannulation: Lithotomy position with feet
reliever 1 hour prior to procedure (acetaminophen,
ibuprofen) in stirrups
◦ Glucagon or butylscopolamine can be used to ▪ Patient's buttocks positioned slightly over edge of
prevent tubal spasm table

▪ Not routinely required ▪ If stirrups are not available, feet placed on
▪ Contraindications to glucagon include fluoroscopy table in frog-leg position with pelvis
pheochromocytoma and insulinoma elevated off table with towels/cushion
◦ Anxiolytics may be helpful in some patients ◦ Contrast administration and imaging: Supine
◦ Antibiotics are not routine but may be considered in position
▪ Patient carefully moved to center of fluoroscopy
select patients in consultation with referring OB/GYN
▪ History of PID: Doxycycline 100 mg p.o. b.i.d. for 5 table after catheter placement and speculum
days beginning 2 days prior to procedure removal
▪ Hydrosalpinx diagnosed on HSG: Doxycycline 100
Equipment Preparation
mg p.o. b.i.d. for 5 days after procedure • Inspect sterile pack to ensure necessary equipment is
• Equipment list available
◦ Private fluoroscopic suite with adequate lighting
• Procedure performed under sterile conditions with
◦ Female chaperone for all fluoroscopists
sterile gloves
◦ Stirrups for fluoroscopy table
• Test inflate catheter balloon and flush catheter with
◦ Sterile equipment
contrast to eliminate air from system
▪ Vaginal speculum
- Disposable plastic speculum with integrated light Procedure Steps
source • Careful and detailed procedural explanation and
- Sterile metal speculum; single-sided specula patient reassurance is vital
make removal around catheter easier • Obtain written and oral informed consent
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• Insert sterile lubricated speculum into vagina and ◦ Smooth uterine cavity contour, patent fallopian
obtain clear view of cervical os tubes, and bilateral free peritoneal spillage of contrast
• Sterilize cervix 3x using iodine solution medium
◦ Can use noniodinated agent for patients with iodine ◦ Other normal findings include myometrial folds, C-
allergy section scar/defect, endocervical gland opacification
• Cannulate cervical os with a 5-French HSG catheter • Abnormal findings
◦ Use catheter stiffener to help guide catheter through ◦ Uterine abnormalities
external os ▪ Congenital abnormalities/müllerian duct
◦ Pass catheter as far as possible into endometrial anomalies
lumen ▪ Luminal filling defects (endometrial polyps,
◦ Alternatively, catheter/balloon may be positioned synechia, fibroids)
in endocervical canal, but usually results in greater ▪ Adenomyosis
patient discomfort ◦ Tubal occlusion (postinflammatory or after occlusive
• Fully inflate balloon (slowly), or to extent that patient procedure)
can tolerate ◦ Other tubal abnormalities: Hydrosalpinx, tubal
◦ Do not over inflate balloon with more air than in adhesions, loculated spillage (indicative of local
syringe adhesions or peritoneal inclusion cyst)
• Gently provide traction on catheter to ensure • Venous/lymphatic intravasation can be seen with
positioning within endometrial lumen and seat against increased/excessive contrast injection pressure
internal os ◦ Progressive opacification of uterine arcuate,
◦ Cervix should slightly bulge with gentle traction parametrial, and pelvic venous vasculature
• Carefully withdraw speculum from vagina, making sure ◦ Seen in up to 6% of patients, though more common
to not dislodge catheter in setting of tubal occlusion
◦ Some fluoroscopists leave speculum in place, though ◦ No clinical significance in isolation
this may obscure pathology
• Obtain a scout radiograph of pelvis with catheter in
Alternative Procedures/Therapies
• Radiologic
place before contrast medium is instilled
◦ Sonohysterography
• Under fluoroscopic imaging, slowly instill iodinated
▪ Similar technique
contrast medium
▪ No ionizing radiation
◦ Avoid air bubbles as they can hinder interpretation
▪ Real-time imaging
◦ Typically < 10 mL of contrast is necessary
▪ Superior for evaluation of endometrium (abnormal
• Obtain spot radiographs after contrast instillation
◦ Early frontal filling view of uterus: Evaluate for any uterine bleeding, polyps) and ovaries
▪ Less accurate for tubal patency
filling defects or contour abnormalities
- Can infer tubal patency by pooling of saline in
◦ Frontal view of fully distended uterus: Evaluate
uterine morphology cul-de-sac
◦ MR
◦ Bilateral shallow oblique frontal views: Evaluate
fallopian tubes
▪ Assessment of entire pelvis
◦ Delayed frontal view of uterus: Document free
▪ Multiplanar imaging capability and superb tissue
intraperitoneal spillage of contrast material
• Additional spot radiographs are necessary to document contrast
▪ Best used for evaluation of uterine congenital
any abnormality
• Oblique views of fallopian tubes help to "elongate" tube anomalies, myometrium, and ovaries
◦ Ultrasound (US)
and displace superimposed structures
• If no free intraperitoneal spill of contrast is visualized,
▪ Real-time imaging
continue gentle contrast medium injection
▪ 3D US can be used to evaluate uterine morphology
◦ If occlusion is due to tubal spasm, continued
injection will opacify tube after spontaneous in cases of suspected müllerian duct anomalies
▪ 3D US may also be used in evaluation of
relaxation
◦ Glucagon or butylscopolamine may be administered endometrial polyps
• Surgical
in cases of suspected tubal spasm, though not
◦ Hysteroscopy
regularly performed
◦ Stop injection if contrast intravasation is observed or ▪ Direct visualization of uterine cavity
▪ Limited evaluation of fallopian tubes
if patient is too uncomfortable
• ◦ Laparoscopic evaluation with dye test
"Pull-back" view may be obtained to evaluate lower
▪ Requires general anesthesia
uterine segment obscured by inflated balloon
◦ Balloon is deflated and catheter is partially ▪ Uterine cannulation is performed under direct
withdrawn into endocervical canal visualization

◦ Gently inject more contrast and reimage lower ▪ Methylene blue contrast is injected into uterine
uterine segment cavity

▪ Spill of methylene blue is visualized via laparoscope
Findings and Reporting into peritoneal cavity
• Normal findings ▪ Ovaries can be evaluated
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▪ Traditional gold standard in evaluation of • Balloon may obscure a lower uterine segment
infertility, though invasive and typically not abnormality
necessary ◦ Consider deflating balloon and carefully retracting
• Other catheter into endocervical canal
◦ Hormone profile as part of infertility work-up ◦ Slowly inject additional contrast and obtain a "pull-
◦ Chlamydia serology for PID back" view of lower uterine segment
◦ Evaluation for male factor in the work-up of
infertility
Complications
• Most feared complication(s)
◦ Irradiation of an early unsuspected pregnancy
POST-PROCEDURE ▪ Appropriate timing of procedure and negative
Expected Outcome pregnancy test before procedure minimizes risk
• Significant complications are rare ◦ Post-HSG infection/PID is uncommon; seen in
• Minor pain and cramping 1.4-3.4% of cases
◦ During positioning of catheter and inflation of ▪ Higher rates of postprocedure infection in cases of
balloon dilated fallopian tubes (11%)
◦ Also secondary to uterotubal distension or peritoneal • Other complications
spill ◦ Pain
▪ Reduced by slow injection of contrast medium ▪ Cramping pain is generally minor and well
◦ Self-limited, usually resolves quickly tolerated by majority of patients
◦ Treated with over-the-counter NSAIDs ▪ Typically resolves by end of examination
• Minor bleeding: Light spotting after procedure, usually ◦ Vasovagal reaction
lasting < 24 hours ▪ Secondary to cervical manipulation or inflation of
• Higher rates of fertility after HSG are reported, though balloon
this relationship is controversial ◦ Allergic reaction to iodinated contrast
▪ Systemic reaction more common with contrast
Things to Do intravasation
• Instruct patients to expect passage of small amount of ◦ Uterine or tubal perforation
contrast from vagina ▪ Extremely rare with conventional flexible HSG
◦ May be tinged with blood
catheters
◦ Patients should use a pad and avoid tampon use
• Instruct patients to watch for signs of possible infection
◦ Development of fever or foul-smelling vaginal SELECTED REFERENCES
discharge 2-4 days following HSG 1. Maheux-Lacroix S et al: Hysterosalpingosonography
for diagnosing tubal occlusion in subfertile women: a
OUTCOMES systematic review protocol. Syst Rev. 2:50, 2013
2. Trad M et al: Müllerian duct anomalies and a case study of
Problems unicornuate uterus. Radiol Technol. 84(6):571-6, 2013
• Difficulty in identifying cervix 3. Carrascosa PM et al: Virtual hysterosalpingography: a new
◦ Remove speculum and perform limited bimanual multidetector CT technique for evaluating the female
reproductive system. Radiographics. 30(3):643-61, 2010
examination to palpate cervix and better direct
4. ACOG Committee on Practice Bulletins--Gynecology:
speculum ACOG practice bulletin No. 104: antibiotic prophylaxis for
◦ For patients with redundant vaginal tissue obscuring
gynecologic procedures. Obstet Gynecol. 113(5):1180-9,
cervix, cut tip from finger of large sterile glove and 2009
place over speculum to prevent intrusion of lateral 5. Chalazonitis A et al: Hysterosalpingography: technique and
tissue into field of view applications. Curr Probl Diagn Radiol. 38(5):199-205, 2009
• Failure to cannulate cervical os 6. Lindheim SR et al: Hysterosalpingography and
◦ Can be difficult in cases of cervical stenosis sonohysterography: lessons in technique. AJR Am J
◦ Use progressive cervical dilators to help pass catheter Roentgenol. 186(1):24-9, 2006
7. Perquin DA et al: Routine use of hysterosalpingography
◦ Can use tenaculum to provide cervical traction,
prior to laparoscopy in the fertility workup: a multicentre
though usually not necessary randomized controlled trial. Hum Reprod. 2006
• Inadequate uterine filling either due to pain or 8. Simpson WL Jr et al: Hysterosalpingography: a reemerging
inadequate seal of balloon against cervix study. Radiographics. 26(2):419-31, 2006
◦ Inject contrast medium more slowly if pain occurs 9. Spring DB et al: Enhanced fertility after diagnostic
◦ Provide gentle traction on catheter during injection hysterosalpingography may be a myth. AJR Am J
to help seat balloon against internal os and reduce Roentgenol. 183(6):1728, 2004
10. Unterweger M et al: Three-dimensional dynamic MR-
contrast reflux
hysterosalpingography; a new, low invasive, radiation-free
◦ Consider different cannula if problems with seal
and less painful radiological approach to female infertility.
persist Hum Reprod. 17(12):3138-41, 2002
• Tubal spasm may lead to false-positive result 11. Ubeda B et al: Hysterosalpingography: spectrum of normal
◦ Repeat injection or give antispasmodic (glucagon) variants and nonpathologic findings. AJR Am J Roentgenol.
• Presence of blood clots in endometrial cavity may 177(1):131-5, 2001
mimic polyps
◦ Ensure no bleeding/spotting on day of examination
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Balloon-Tipped
Typical Hysterosalpingogram Tray Hysterosalpingogram Catheter
(Left) Included in a typical
HSG tray are ring forceps/
tenaculum used to sterilize
the cervix, speculum ,
iodine-based cleanser , and
lubricating gel . A uterine
sound is often included
but rarely used. (Right)
Image demonstrates a typical
balloon-tip HSG catheter. The
inflatable balloon is shown
along with the plastic catheter
stiffener , the contrast-filled
syringe , the syringe to
inflate the balloon, and the
balloon stopcock .
Normal HSG Müllerian Duct Anomaly

(Left) Frontal image shows a
normal HSG, with a smooth
endometrial contour. The
fallopian tube segments are
well visualized (interstitial ,
isthmic , ampullary ) and
there is free spill of contrast
from each tube. (Right)
Frontal image shows 2 uterine
cavities separated by a
thick intervening septum .
There was a single cervix. This
may represent a septate or
bicornuate uterus; MR or 3D
US is necessary to evaluate the
external uterine contour.
Tubal Occlusive Contraceptive Devices Tubal Occlusion With Filling Defect

(Left) Frontal image shows
bilateral Essure tubal
occlusive devices . This
procedure was performed
to confirm tubal occlusion
after device placement.
Note the small amount of
contrast intravasation due
to forceful injection. (Right)
Oblique frontal image shows
a large, rounded, fixed filling
defect within the left
uterine cornua, representing
an endometrial polyp. There is
resulting occlusion of the left
tubal orifice. The right tube
is normal.
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Contrast Intravasation Contrast Intravasation
(Left) Frontal image from an
HSG shows the appearance
of contrast intravasation. The
arcuate veins are opacified,
as is the parametrial and
pelvic venous vasculature
. This is often the result of
overdistention of the uterine
lumen &/or injection of contrast
with excessive pressure. (Right)
Frontal image from an HSG
shows contrast intravasation
into the uterine arcuate venous
vasculature , with subsequent
opacification of the parametrial
and pelvic veins .
Tubal Occlusion With Filling Defect Bilateral Tubal Occlusion

(Left) Oblique frontal image from
an HSG shows a normal left tube
without opacification of the
right tube. A subtle rounded
filling defect is noted at the
right tubal orifice, found to be a
small occluding polyp. (Right)
Frontal image shows occlusion of
the bilateral fallopian tubes at
the level of the proximal isthmic
segment. Occlusion can be due
to adhesions/scarring, tubal
spasm, or rarely, tubal polyps.
Air Bubbles Air Bubbles

(Left) Oblique frontal image
from an HSG shows 2 rounded
apparent endometrial filling
defects . These were mobile
throughout the examination
and represented air bubbles
introduced during contrast
administration. The catheter
balloon is seen. (Right)
Frontal image shows numerous
mobile filling defects
within the endometrial lumen,
representing air bubbles. Bubbles
can mimic endometrial polyps
and can be minimized with
meticulous technique.
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Salpingitis Isthmica Nodosa Salpingitis Isthmica Nodosa

the classic appearance of
salpingitis isthmica nodosa
(SIN) with small diverticular
outpouchings arising from
the isthmic segment of the
fallopian tube. SIN can be
associated with infertility.
(Right) Frontal image from an
HSG shows tiny diverticular
outpouchings from the
isthmic segment of the right
fallopian tube, consistent with
SIN, which can affect 1 or
both tubes.
Hydrosalpinx Hydrosalpinx
(Left) Frontal image
demonstrates a dilated and
tortuous left fallopian tube ,
consistent with hydrosalpinx.
There was no free spillage of
contrast from the left tube.
The right fallopian tube
is normal. (Right) Oblique
frontal image shows a dilated
ampullary segment of the right
fallopian tube without
free spillage of contrast. This
appearance is consistent with
hydrosalpinx. The left tube
is normal.
Abnormal HSG Uterine Synechia

2 ovoid fixed filling defects
within the endometrial
lumen, representing polyps.
Note the calcified intramural
fibroid exhibiting mass
effect on the endometrial
lumen. Note the metal vaginal
speculum . (Right) Frontal
image shows irregularity of
the endometrial contour with
several linear filling defects .
In this patient with infertility
and a history of prior dilation
and curettage, this is consistent
with uterine synechia
(Asherman syndrome).
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Müllerian Duct Anomaly Müllerian Duct Anomaly
(Left) Frontal fluoroscopic image
shows a single tubular uterine
horn with an associated
normal fallopian tube ,
consistent with a unicornuate
uterus. MR may be necessary
to evaluate for a contralateral
noncommunicating rudimentary
horn. (Right) Frontal image
demonstrates 2 uterine horns
in this patient with recurrent
pregnancy loss. This appearance
can be seen with septate and
bicornuate uteri. MR or 3D US is
necessary for further evaluation.
Filling Defect Failed Tubal Occlusion

a fixed, somewhat angular
filling defect along the right
endometrial cavity, representing
an endometrial adhesion. Note
the bilateral tubal occlusive
devices . (Right) Frontal
image demonstrates bilateral
contraceptive tubal occlusive
devices . On the right,
contrast opacifies the tube
distal to the device with free
spillage into the pelvis, consistent
with failure of occlusion. The left
tube was occluded.
Hydrosalpinx Salpingitis Isthmica Nodosa

(Left) Frontal fluoroscopic
image in a patient with infertility
demonstrates a dilated and
tortuous right fallopian tube ,
consistent with hydrosalpinx.
The left tube was normal. (Right)
Frontal image shows an irregular
obstructed ampullary segment of
the left fallopian tube . Note
the subtle diverticula along
the isthmic segment, suggestive
of SIN in this patient with a
history of infertility and prior
PID.
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SONOHYSTEROGRAPHY
Techniques
Included in a typical tray are a tenaculum (to sterilize Sagittal transvaginal ultrasound during saline-infused
the cervix), speculum , cleanser , lubricating gel sonohysterogram (SIS) shows distension of the uterine
, a 5-7 French catheter with a 3 mL syringe for the cavity with saline. The endometrium is of uniform
balloon, and a 20 mL syringe containing sterile saline. thickness and homogeneous echotexture.
▪ May be administered to patients who are at

TERMINOLOGY increased risk for infection
Abbreviations Timing
• Saline-infused sonohysterogram (SIS) • Premenopausal women
Definitions ◦ Early proliferative phase (day 4–10) of menstrual
• SIS is a technique that involves placing a catheter into cycle, when endometrium is at its thinnest
▪ Saline can easily distend uterine cavity and better
uterine cavity to inject sterile saline into endometrial
canal accentuate endometrial pathology
▪ Physiologic changes during secretory phase may
PRE-PROCEDURE simulate pathologic conditions

- Irregularities in contour of endometrium may be
Indications misinterpreted as small polyps or focal areas of
• Determine cause of abnormal vaginal bleeding endometrial hyperplasia
◦ In premenopausal women • Postmenopausal women
▪ Distinguish anovulatory bleeding from anatomical ◦ Not undergoing hormone replacement therapy
lesion ▪ Any time
◦ In postmenopausal women ◦ Undergoing sequential hormone therapy (estrogen
▪ Distinguish between atrophy and anatomical followed by progesterone)
lesion that may require biopsy ▪ At end of progesterone phase
• Infertility and repeated abortion
• Congenital abnormality of uterine cavity PROCEDURE
• Preoperative or postoperative evaluation of uterine
myomas, polyps, or cysts Patient Position/Location
• • Lithotomy position
Suspected uterine synechiae
• Further evaluation of suspected endometrial Equipment Preparation
abnormalities detected by transvaginal sonogram • Equipment needed
Contraindications ◦ Sterile speculum with open side
• ◦ Cervical sounds in event that catheter does not pass
Pregnancy
• Active pelvic infection easily through cervix
• ◦ 20 mL syringe
Excessive vaginal bleeding
• ◦ Tenaculum
Patients with IUD in place
▪ Used to clean cervix
Getting Started ◦ Clamps
• Things to check ◦ 5-7 French hysterosonography catheter with a 3 mL
◦ Negative pregnancy test must be documented syringe for balloon
• Medications ▪ Several different catheters available for SIS
◦ Anesthesia or analgesia is not usually required
◦ Nonsteroidal anti-inflammatory drug may be offered Procedure Steps
• Brief bimanual examination to locate cervix
30 minutes prior to examination to help reduce pain
• Speculum is inserted into vagina, and cervical os is
1 of cramping
◦ Prophylactic antibiotics are not routinely advised localized and cleaned with povidone iodine solution
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Techniques
Key Facts
Terminology • Negative pregnancy test must be obtained prior to
• Saline-infused sonohysterogram (SIS) procedure
◦ Technique that involves placing a catheter • Timing
into uterine cavity to inject sterile saline into ◦ Premenopausal women: Early proliferative phase
endometrial canal (day 4–10) of menstrual cycle, when endometrium is
at its thinnest
Pre-Procedure ◦ Postmenopausal women: Generally any time
• Indications Procedure
◦ Determine cause of abnormal vaginal bleeding
◦ Infertility and repeated abortion • Catheter must be flushed with sterile saline before
◦ Congenital abnormality of uterine cavity insertion to remove air bubbles
• Contraindications • Normal uterine cavity should expand symmetrically
◦ Pregnancy upon saline instillation
◦ Active pelvic infection • Endometrium should be uniform in thickness,
◦ Excessive vaginal bleeding homogeneous in echotexture
◦ Patients with IUD in place
• Catheter must be flushed with sterile saline before • Variable uterine position
insertion to remove air bubbles ◦ Can complicate catheter insertion
◦ Air introduced into endometrial canal may obscure ▪ Changing position of speculum by moving handle
abnormalities during scanning of speculum up or down, thus changing angle of
• Catheter is inserted into cervical canal access to cervix
• Catheter balloon tip is then inflated using 1-2 mL of - Often enables successful catheter insertion
saline • Cervical stenosis
• Speculum is removed ◦ Cervical dilator may be used
• Standard transvaginal ultrasound probe is then inserted ◦ Guidewire can be passed through cervical os with
alongside catheter subsequent passage of a non-balloon-tipped catheter
• Warm sterile saline is instilled into endometrial over guidewire into cervical os
cavity via a 20 mL syringe attached to catheter while • Difficult distension of endocervical canal
transducer is moved from side to side (cornua to ◦ Synchronous gentle collapse of catheter balloon
cornua) in a long-axis position while slowly instilling fluid into canal while
• Amount of fluid instilled will vary depending on retracting catheter or passively slipping it out of
distention of uterus and patient tolerance uterus
◦ Usually, amount of saline instilled is 40 mL • Air introduced into endometrial canal, leading to an
• Ideally, all portions of endometrium should be imaged echogenic artifact that can obscure abnormalities
to exclude any abnormalities ◦ Flushing catheter with saline before procedure is
essential
Findings and Reporting • Backflow of saline around balloon and through cervix
• Normal uterine cavity should expand symmetrically
→ under distension of uterine cavity → masking of
upon saline instillation
endometrial pathology
• Endometrial thickness ◦ Gently retract inflated catheter balloon to occlude
◦ Premenopausal
internal cervical os
▪ No established limit for normal
• Balloon hyperinflation may obscure underlying
▪ Endometrium should be uniform in thickness,
pathology
homogeneous in echotexture ◦ Move or partially deflate balloon
◦ Postmenopausal
▪ Normal atrophic endometrium should measure < Complications
2.5 mm in single-layer thickness • Pelvic pain (3.8% of patients)
▪ Atrophic endometrium should be smooth and • Vagal symptoms (3.5% of patients)
uniform in echotexture • Nausea (1% of patients)
• SIS can determine whether endometrium is diffusely • Postprocedure fever (0.8% of patients)
thick or has focal areas of thickening • Rarely, endometritis
◦ Diffuse thickening → blind endometrial biopsy
◦ Focal areas of thickening → hysteroscopic biopsy
SELECTED REFERENCES
OUTCOMES 1. Yang T et al: Sonohysterography: Principles, technique and
role in diagnosis of endometrial pathology. World J Radiol.
Problems 5(3):81-7, 2013
• Failure to complete procedure 2. Allison SJ et al: saline-infused sonohysterography: tips for
◦ achieving greater success. Radiographics. 31(7):1991-2004,
Patient discomfort
2011
◦ Cervical stenosis and scarring, leading to difficult
catheterization and backflow of saline 1
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Techniques
Axial CECT shows the normal appearance of the uterus Sagittal CECT shows the normal appearance of the uterus
. The central endometrium appears hypodense, and . Most uteri are anteverted and anteflexed, as in
the outer myometrium can have a variable pattern of this case. The central hypodense endometrium is best
enhancement. measured on sagittal images.
◦ Avoid intravenous contrast

TERMINOLOGY • Allergy to iodinated contrast is a relative
Abbreviations contraindication
• ◦ Requires premedication, typically with oral steroids
Computed tomography (CT)
• Computed tomography angiography (CTA) and diphenhydramine
◦ Consider noncontrast examination or alternate
PRE-PROCEDURE modality
Indications Getting Started

• Things to check
• Staging of known/presumed ovarian cancer
◦ Check renal function in patients receiving iodinated
◦ Evaluate extent of disease (peritoneal spread of
disease, nodal involvement, malignant ascites) contrast if
▪ Patient is > 60 years in age
◦ Helps to guide patients to surgery or neoadjuvant
▪ History of renal impairment
chemotherapy
▪ History of hypertension requiring medication
• Local staging of advanced pelvic malignancies (such as
▪ History of diabetes
uterine and cervical carcinoma)
▪ Patient is taking metformin
◦ MR is typically modality of choice
◦ CT may be helpful when MR is contraindicated
• Follow-up of treated gynecologic malignancy
PROCEDURE
◦ Assess for tumor recurrence
Patient Position/Location
• Assessing postoperative complications • Patient is typically in supine position
◦ Abscess
• Prone or oblique imaging may be necessary for CT-
◦ Fistula
guided procedures
◦ Lymphocele
• Assessment of pelvic infectious processes Alternative Procedures/Therapies
◦ Tubo-ovarian abscess/pyosalpinx • Radiologic
◦ Pyometra/myometrial abscess in clinical setting of ◦ US
endometritis ◦ MR
• Localization of IUD when not visualized on ultrasound
• CT-guided biopsy
Advantages
• Oral and rectal contrast opacification of gastrointestinal
◦ Provides a histological diagnosis
◦ Helps to differentiate tumor recurrence from tract
◦ Allows differentiation of bowel from pelvic viscera
postsurgical/radiation fibrosis
• and tumor
CT-guided drainage of pelvic collection
• Intravenous contrast enhancement of blood vessels and
• CT is not typically used as first-line examination to
viscera
characterize gynecological pathology
◦ Helps improve soft tissue differentiation
◦ US and MR are typically utilized
▪ Pelvic blood vessels vs. lymph nodes vs. parametrial
Contraindications tumor extension
• CT is not contraindicated in pregnancy but should be ◦ Angiographic imaging can assess pelvic vascular
used judiciously involvement
1 ◦ US and MR should be considered 1st
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Key Facts
Pre-Procedure ◦ Use of ionizing radiation
◦ Contrast agents have associated morbidity/mortality
• Indications for CT imaging include ◦ Limited application in early cancer and local staging
◦ Staging of known/presumed ovarian cancer
◦ Follow-up of treated gynecologic malignancy Procedure
◦
◦
Assessing postoperative complications
Assessment of pelvic infectious processes
• Imaging is typically performed with oral and IV
contrast
◦ Procedural guidance
• While CT is not the study of choice in evaluation of
• CT is not contraindicated in pregnancy but should be gynecological pathology, pelvic organs are routinely
used judiciously imaged and described in imaging report
• Advantages of CT imaging include ◦ Uterus: May have variable enhancement patterns
◦ Quick imaging times ◦ Cervix: Typically has a targetoid appearance
◦ Isotropic voxels allow for improved multiplanar ◦ Fallopian tubes: Usually not well visualized when
reconstruction normal
◦ Intraluminal contrast allows for easy distinction of ◦ Ovaries: Easily seen in premenopausal patients,
bowel from pelvic organs/pathology but atrophic and often difficult to visualize after
• Disadvantages of CT include menopause
◦ Differential enhancement patterns distinguish ◦ 2-5 mm thick axial images

uterine tumor from normal myometrium ◦ Sagittal and coronal images
◦ Allows opacification of bladder and ureters ◦ 3D reconstructed images as needed
• Multidetector CT provides for very fast data acquisition • CT cystography can be performed to evaluate bladder
◦ Rapid coverage of entire body involvement by tumor or urogenital fistula
◦ High spatial resolution ◦ Imaging performed after bladder catheterization and
▪ Acquisition of isotropic voxels allows for improved instillation of contrast
multiplanar reconstruction ◦ Intravenous contrast is administered as well
◦ Imaging in different circulatory phases can be ◦ Consider negative intravaginal contrast to better
acquired visualize fistula
• CT hysterosalpingography techniques have been
Disadvantages described
• Utilizes ionizing radiation ◦ Involves catheterization of endometrial cavity and
• Image quality may be degraded by injection of dilute iodinated contrast material
◦ Body habitus
◦ CT of pelvis is performed with multiplanar and 3D
◦ Metallic hardware (hip prosthesis)
reformatted images
• Use of iodinated contrast agents associated with ◦ Allows for evaluation of tubal patency and uterine
morbidity and mortality morphology
• Limited application in early-stage cancer and local ◦ Can perform "virtual hysteroscopy" and evaluate
staging endometrial contour
CT Technique CT Anatomy
• Preprocedural administration of oral contrast medium • Uterus
◦ 750-1,000 mL diluted positive oral contrast 2 hours
◦ Appearance varies depending on
prior to examination ▪ Patient age
▪ Barium or iodine based
▪ Uterine positioning
◦ Delayed oral contrast medium regimen (48 hours)
▪ Parity
may be useful if slow transit through gut ▪ Presence of leiomyoma, adenomyosis
• IV contrast medium administration ◦ Typically appears as a triangular soft-tissue structure
◦ 100-150 mL iodinated contrast medium
contiguous with vagina
▪ Injection rate 2-3 mL/second for routine studies
▪ Uterus is anteverted/anteflexed in most cases
▪ Rate of 4-5 mL/second for angiographic
▪ May appear enlarged on axial images if retroflexed/
applications retroverted
◦ Images acquired 70-120 seconds after contrast for
◦ Posterior to urinary bladder, anterior to rectum
routine studies ◦ NECT: Uterus appears homogeneous; measures soft
▪ Bolus tracking technique vs. 20-40 second delay
tissue attenuation
after contrast injection ▪ Central endometrium may be faintly visible as a
▪ Delayed imaging may be useful
slightly hypodense stripe
- 3-5 minutes for pelvic vein imaging (for patency/
◦ CECT: Differential enhancement of myometrium and
thrombosis) endometrium
- 5-10 minutes for bladder and ureteral
▪ Varied enhancement of myometrium based on
opacification timing of study, phase of menstrual cycle, patient
• Sub-mm collimation images are acquired and age
reconstructed into - Homogeneous (diffuse or minimal)
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- Subendometrial (thick or thin) ▪ Frequently seen

- Outer myometrial ◦ Uterosacral ligament
- Patchy/heterogeneous ▪ Extends posteriorly from lateral cervix and vagina
▪ Myometrium enhances to a lesser degree in ▪ Tapers toward anterior body of S2 or S3
postmenopausal patients ▪ May be seen as soft tissue arcing band from cervix
▪ Endometrium enhances to a lesser degree on early- to sacrum
phase acquisitions and becomes more isodense to ◦ Cardinal ligament
myometrium on delayed imaging ▪ Extends laterally from cervix and upper vagina
- Endometrial thickness may be overestimated on ▪ Merges with pelvic sidewall
axial and coronal images; sagittal reformatted ▪ May be seen as triangular soft tissue structure
images provide for more accurate measurement ▪ Contains uterine vasculature
• Cervix ◦ Ovarian ligaments
◦ Inferior segment of uterus, contiguous with vagina ▪ Not usually identified
◦ Rounded appearance in axial plane ▪ Proper ovarian ligament: Extends medially from
◦ NECT: Homogeneous soft tissue density, isodense to ovary to uterus
myometrium - Arises inferior to fallopian tube ostium
◦ CECT: Targetoid/layered appearance ▪ Suspensory ligament of ovary: Extends from ovary
▪ Central secretions/fluid: Hypodense to pelvic sidewall
▪ Inner cervical mucosa: Hyperdense - Contains ovarian vasculature
▪ Inner stroma: Hypodense
▪ Outer stroma: Hyperdense OUTCOMES
▪ On early postcontrast phases, cervix may appear
diffusely low density and simulate pathology Complications
• • Most feared complication(s)
Fallopian tubes
◦ Normally not well visualized ◦ Anaphylactoid reaction to intravenous contrast
◦ May appear as tortuous tubular structure in setting of administration
• Other complications
hydrosalpinx/pyosalpinx
• ◦ Contrast-induced nephropathy for patients receiving
Vagina
◦ Thin-walled tubular structure extending from cervix intravenous iodinated contrast
to introitus
◦ Typically collapsed; may contain a small amount of SELECTED REFERENCES
air, fluid, or tampon
◦ Characteristic "H" configuration
1. Katz DS et al: Computed tomography imaging of the acute
pelvis in females. Can Assoc Radiol J. 64(2):108-18, 2013
◦ Mucosa will demonstrate smooth enhancement
2. Botsikas D et al: A new MDCT technique for the detection
• Ovaries and anatomical exploration of urogenital fistulas. AJR Am J
◦ Routinely seen in premenopausal women Roentgenol. 198(2):W160-2, 2012
◦ Small and atrophic in postmenopausal patients; not 3. Sierra A et al: Utility of multidetector CT in severe
always identified postpartum hemorrhage. Radiographics. 32(5):1463-81,
▪ Often located adjacent to external iliac vasculature 2012
◦ Can be identified by following ovarian vasculature 4. Yitta S et al: Normal or abnormal? Demystifying uterine
and cervical contrast enhancement at multidetector CT.
into pelvis Radiographics. 31(3):647-61, 2011
◦ Uniform soft-tissue density, lower than that of
5. Carrascosa PM et al: Virtual hysterosalpingography: a new
enhancing myometrium multidetector CT technique for evaluating the female
▪ Small low-density cystic regions represent follicles reproductive system. Radiographics. 30(3):643-61, 2010
▪ Irregular thick-walled enhancing structure 6. Yitta S et al: Added value of multiplanar reformation in the
represents corpus luteum multidetector CT evaluation of the female pelvis: a pictorial
◦ Position variable review. Radiographics. 29(7):1987-2003, 2009
▪ Usually posterolateral to uterine corpus 7. Chen MM et al: Guidelines for computed tomography and
▪ Anterior and medial to ureter
magnetic resonance imaging use during pregnancy and
lactation. Obstet Gynecol. 112(2 Pt 1):333-40, 2008
▪ Posterior to round ligament
8. Grossman J et al: Efficacy of contrast-enhanced CT
▪ Medial or posteromedial to external iliac vessels in assessing the endometrium. AJR Am J Roentgenol.
▪ Ovarian mass displaces ureter laterally and 191(3):664-9, 2008
posteriorly vs. nodal mass lying lateral to ureter 9. Choi HJ et al: Computed tomography findings of ovarian
• Pelvic ligaments metastases from colon cancer: comparison with primary
◦ Broad ligament malignant ovarian tumors. J Comput Assist Tomogr.
▪ 2 layers of peritoneum 29(1):69-73, 2005
▪ Extend laterally from uterus to pelvic sidewall
10. Funt SA et al: Role of CT in the management of recurrent
ovarian cancer. AJR Am J Roentgenol. 182(2):393-8, 2004
▪ Contains parametrial vasculature
11. Saksouk FA et al: Recognition of the ovaries and ovarian
▪ Not usually seen unless ascites is present origin of pelvic masses with CT. Radiographics. 24 Suppl
◦ Round ligament 1:S133-46, 2004
▪ Thin soft tissue attenuation band
▪ Extends laterally from lateral fundus to internal
inguinal ring
1 ▪ Tapers distally
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Cervix Ovaries
(Left) Axial CECT shows the
normal targetoid appearance
of the cervix . The central
secretions are hypodense, the
mucosa is hyperdense, the
inner stroma is hypodense, and
the outer cervical stroma is
hyperdense. (Right) Axial CECT
shows normal-appearing ovaries
, which may be more difficult
to identify in postmenopausal
patients due to atrophy. The
ovaries appear hypodense to the
myometrium, with numerous
small physiologic follicles.
Broad Ligaments Round Ligaments

(Left) Axial CECT demonstrates
the broad ligaments as they
arise from the lateral margins
of the uterus and extend
laterally. The broad ligaments
are normally difficult to identify
unless they are outlined by
ascites or, as in this case,
intraperitoneal oral contrast.
(Right) Coronal CECT shows the
round ligaments as they arise
from the uterine fundus and
extend into the inguinal canals.
The round ligaments are typically
well visualized on CT.
Uterosacral Ligaments Vagina

(Left) Axial CECT shows normal
bilateral uterosacral ligaments
, which can be seen as thin
soft tissue bands extending from
the lateral cervical margins
posteriorly to the sacrum. The
uterosacral ligaments can be a
route of disease spread, as in
the setting of cervical carcinoma
or endometriosis. (Right)
Axial CECT shows a normal
appearance to the decompressed
vagina , which classically
has an "H" configuration. The
vaginal mucosa is typically
smoothly enhancing.
1
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Techniques
Sagittal T2WI MR shows normal MR appearance of Axial T2WI MR demonstrates a normal appearance of the
uterus, which is anteverted and anteflexed; uterine zonal ovaries and uterus . Within the ovaries are scattered
anatomy is well visualized. Note cesarean section scar small physiologic follicles. Note the normal uterine zonal
along anterior aspect of lower uterine segment. anatomy.
◦ Acute kidney injury

TERMINOLOGY • Relative contraindications to MR include
Definitions ◦ Tattoos, including permanent eye liner
• ◦ Patients who suffer with claustrophobia
Imaging modality that measures tissue response to
◦ Compromised thermoregulatory systems
radiofrequency pulses in a magnetic field to generate
• Any implanted device must be confirmed safe for
images
MR prior to imaging
PRE-PROCEDURE Getting Started
• Things to check
Indications
◦ Evaluation of renal function for patients receiving
• Characterization of pelvic masses
• Staging of pelvic malignancies contrast who meet the following criteria
▪ > 60 years of age
• Evaluation of congenital (müllerian) anomalies
▪ History of renal disease
• Treatment follow-up
▪ History of hypertension requiring medication
• Pelvic floor assessment (dynamic)
▪ History of diabetes mellitus
• Evaluation of pelvic lymphadenopathy
• Medications
• Pelvimetry
◦ Anxiolytics may be helpful in patients with
• Evaluation of pelvic pain in pregnancy
claustrophobia
Contraindications ◦ Antiperistaltic agents (hyoscine butyl bromide or
• Cardiac pacemakers/implantable cardioverter- glucagon) may be used to limit small bowel motion
defibrillators artifact
◦ Alternative modalities should be pursued • Patient preparation
◦ Patients who are not pacemaker-dependent may ◦ Empty bladder
undergo MR evaluation in experienced centers under ◦ Reduce motion artifact from small bowel peristalsis
supervision of cardiologist if there are no suitable ▪ Fasting for 4-6 hours before MR examination
alternatives ▪ Antiperistaltic agent use is not routine
• Cochlear implants ◦ Vaginal administration of 40-60 mL of bacteriostatic
◦ Certain devices may be safe for MR imaging surgical lubricant may be considered
• Ferromagnetic intracranial aneurysm clips ▪ Acts as intraluminal contrast agent
• Implanted neurostimulators ▪ Allows for improved evaluation of cervix and
◦ Certain devices may be safe for MR imaging vagina
• Ferromagnetic foreign bodies (intraocular)
• Pulmonary artery monitoring catheters, temporary
Advantages
• No ionizing radiation
transvenous pacing leads, intraaortic balloon pumps,
• Multiplanar capability
LVADs
• Excellent spatial and tissue contrast resolution, which is
• Intravenous gadolinium contrast should not be
improved with higher field magnets (3T)
administered in patients at risk for nephrogenic
• Can perform dynamic imaging, allowing for functional
systemic sclerosis
◦ Chronic renal insufficiency with an estimated evaluation
• Allows definitive noninvasive diagnosis of certain
glomerular filtration rates < 30 mL/min
1 ◦ Dialysis patients malignant tumors and benign conditions
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Key Facts
Procedure ◦ In supine position using a surface array
• Indications for MR include multichannel coil
◦ In axial, sagittal, coronal, and oblique planes
◦ Characterization of adnexal masses
◦ Staging of pelvic malignancies • Sequences utilized depend on clinical problem but
◦ Evaluation of congenital anomalies typically include T2WI, T1WI, and pre- and post-
◦ Treatment follow-up contrast T1WI FS
◦ Pelvic floor assessment • Gynecological anatomy is well-appreciated on MR
◦ Imaging of pelvic pain during pregnancy ◦ Uterine and cervical zonal anatomy is well depicted
• Contraindications for MR include implanted medical on sagittal T2WI
◦ Ovaries are visualized in the ovarian fossae, usually
devices, ferromagnetic foreign bodies
◦ Any implanted device must be confirmed safe containing scattered physiologic follicles &/or
for MR prior to imaging corpus luteum
◦ Intravenous gadolinium contrast should not be ◦ Appearance of pelvic organs varies with age,
administered in patients at risk for nephrogenic menstrual status, and parity
systemic sclerosis
• Image is typically performed
▪ Good for evaluation of parametrium (i.e.,

Disadvantages
• Longer acquisition times parametrial tumor extension)
◦ Sagittal plane
• May not be as widely available as CT or US
▪ Best appreciation of uterine zonal anatomy
• Increased cost
▪ Useful in evaluation of tumor extension to bladder,
PROCEDURE cervix, rectum, and vagina

◦ Coronal plane
Patient Position/Location ▪ Provides complementary information in
• Patient is usually imaged in supine position assessment of uterus, cervix, parametrium, vagina,
and ovaries
Equipment Preparation ▪ Evaluation of lymphadenopathy and adnexal
• Coil selection masses
◦ Image commonly performed using surface array
◦ Oblique planes (axial &/or coronal)
multichannel coil ▪ Very helpful in evaluation of parametria in patients
◦ Abdominal/pelvic coil provides for larger field of view
with cervical cancer
but decreased resolution/signal ▪ Allows for characterization of müllerian duct
◦ Phase-array coil increases resolution and decreases
anomalies
imaging time • Sequences most commonly utilized include
◦ Endoluminal coils (endorectal and endovaginal coils)
◦ T2WI: Superb tissue contrast resolution and
may be used in select cases demonstration of uterine and cervical zonal anatomy
▪ Advantage: Provide for high-resolution images,
and ovarian anatomy
especially small cervical tumors or those with ▪ Imaging performed without fat suppression; pelvic
limited parametrial invasion fat serves as intrinsic contrast
▪ Disadvantage: Limited field of view that proves
◦ T1WI: Evaluation of pelvic soft tissues, lymph nodes,
inadequate in assessing large tumors and and bone marrow
extrauterine tumor extent ◦ T1WI FS
Alternative Procedures/Therapies ▪ Helps to differentiate between fat and blood
• ▪ Improves detection and conspicuity of
Radiologic
◦ Ultrasound hyperintense lesions surrounded by fat
▪ Useful in initial evaluation of gynecological ▪ Provides baseline pre-contrast signal intensity to
complaints compare to post-gadolinium imaging

▪ Can help characterize uterine/adnexal lesions ◦ T1WI C+ FS
◦ CT ▪ Helps in characterization of adnexal lesions
▪ Most useful in staging of malignancy (extrapelvic ▪ Essential in cervical cancer staging
- Evaluation of extent of tumor (vaginal,
involvement, lymphadenopathy)
▪ Used in follow-up of treated malignancy parametrial, pelvic sidewall)
▪ Useful in evaluation of suspected tubo-ovarian - Helps identify bladder, ureteral, or rectal
abscess involvement
- Pelvic lymphadenopathy
MR Technique ▪ Useful in staging ovarian cancer (when CT is not
• Imaging planes performed)
◦ Axial plane ▪ Evaluation of vascularity of uterine leiomyomata
▪ Pelvic anatomy is typically best recognized in axial
plane
prior to therapy
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▪ Can be performed dynamically to evaluate lesion ▪ Can evaluate for tubal patency as well as structural
enhancement characteristics abnormalities
◦ Diffusion weighted imaging (DWI)/apparent ◦ BOLD (blood oxygenation level dependent) MR
diffusion coefficient (ADC) ▪ Measures differences in paramagnetic
▪ Must be evaluated in conjunction with other deoxyhemoglobin in blood as a marker of tumor
imaging sequences hypoxia
▪ Provides information about water mobility, tissue ▪ Tumors with higher levels of hypoxia may be more
cellularity, and integrity of cellular membranes aggressive and resistant to therapy
▪ Aids in diagnosis and grading of tumors as well as ▪ Identifies higher grade portions of tumor to help
predicting/assessing response to treatment guide therapy
- Low ADC values are associated with malignancy ◦ MR lymphography
(such as endometrial, ovarian, and cervical ▪ Can detect metastases in normal size lymph nodes
cancers), though there is overlap between with very high sensitivity and specificity
malignant and benign tissues ▪ Requires intravenous injection of ultra small
- Tumors with low cellularity or mucinous tumors particles iron oxide (USPIO)
may have high ADC values ▪ USPIO is taken up by normal lymph nodes, whereas
- Pretreatment ADC values may help predict metastatic lymph nodes show no uptake
tumor response to therapy ◦ Diffusion tensor imaging (DTI)
▪ Peritoneal implants from disseminated ovarian ▪ Can help detect and quantify defects/asymmetries
cancers often have restricted diffusion in pelvic floor musculature
- Small implants are more conspicuous than on ▪ Provides 3D representation of pelvic floor skeletal
other sequences muscle
▪ ADC values of malignant lymph nodes are typically ◦ MR defecography
lower than that of normal nodes ▪ Imaging performed after rectal administration
- Inflammatory/reactive nodes may also have low of contrast (typically ultrasound gel) to evaluate
ADC values pelvic floor
▪ Can help distinguish recurrent/residual tumor ▪ Multiphase dynamic imaging performed (at rest,
from postoperative change strain, defecation) typically with fast T2 imaging or
- Viable tumors have low ADC values, whereas bright-blood techniques
postoperative inflammation has higher ADC
values
MR Anatomy
• Uterus
▪ DWI/ADC can be used to monitor treatment of
◦ Divided into uterine body/corpus and cervix
leiomyomas
▪ Normal fallopian tubes usually not well seen
- Treated lesions have increased DWI/decreased
◦ Appearance varies with age of patient, hormonal
ADC signal due to infarct-related diffusion
restriction status, parity
◦ Size: Varies with patient age
- ADC values may subsequently increase
▪ Premenarche: Body and cervix are nearly same size;
secondary to necrosis
• Other imaging sequences/techniques include uterus measures 2.5-3.5 cm in length
▪ Childbearing age: Body is much larger than cervix;
◦ Steady-state free precession (SSFP)
▪ "Bright blood" imaging technique uterus measures 6-10 cm in length
▪ Postmenopause: Body atrophies
▪ Fast imaging sequence, relatively motion
◦ Positioning
insensitive
▪ Uterus is centrally positioned within pelvis, though
▪ Can be acquired dynamically in evaluation of
pelvic floor dysfunction may be laterally deviated
▪ Typically anteverted and anteflexed, though highly
▪ Useful in imaging of pregnant patients
◦ Pelvic MRA variable
◦ MR signal characteristics
▪ Evaluation of pelvic vasculature prior to procedure
▪ T1WI: Uterus is of low to intermediate signal
(uterine artery embolization)
▪ Evaluation for vascular involvement by pelvic intensity
▪ T2WI: Uterine zonal anatomy is well visualized
malignancy
- Endometrium: Central band of uniform high
◦ MR perfusion
▪ Displays information about tissue perfusion, signal intensity that varies in thickness with
microcirculation, and angiogenesis patient age and phase of menstrual cycle
- Junctional zone: Innermost myometrium layer of
▪ Aids in lesion detection and characterization and
can improve accuracy of tumor staging low SI
- Outer myometrium: Intermediate SI, higher than
▪ Changes in tumor perfusion as a marker of early
response to treatment may precede decrease in striated muscle
- Zonal anatomy less distinct in premenarche,
tumor size
◦ MR hysterosalpingography postmenopausal patients, and at menstruation
▪ T1WI C+ FS: Homogeneous enhancement of
▪ MR imaging is performed after cannulation of
cervix and injection of dilute gadolinium contrast myometrium
- Endometrium enhances to a lesser degree than
into endometrial cavity
1 myometrium on early post-contrast phases, more
isointense on delayed imaging
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▪ Parametrium: Intermediate SI on T1WI and
variable SI on T2WI
SELECTED REFERENCES
▪ Uterine appearance may vary with exogenous 1. Sala E et al: The added role of MR imaging in treatment
hormonal therapy stratification of patients with gynecologic malignancies:
▪ DWI what the radiologist needs to know. Radiology.
- Normal endometrium appears hyperintense to
266(3):717-40, 2013
2. Wakefield JC et al: New MR techniques in gynecologic
myometrium cancer. AJR Am J Roentgenol. 200(2):249-60, 2013
- Junctional zone is hypointense 3. Beddy P et al: FIGO staging system for endometrial cancer:
• Cervix added benefits of MR imaging. Radiographics. 32(1):241-54,
◦ Fibromuscular tubular portion of uterus between 2012
uterine body and vagina 4. Freeman SJ et al: The revised FIGO staging system for uterine
◦ Typically 2.5-3 cm in length in nongravid women malignancies: implications for MR imaging. Radiographics.
▪ Up to 6 cm in length during pregnancy 32(6):1805-27, 2012
▪ Cervical diameter is typically 3-4 cm
5. Haldorsen IS et al: Staging of endometrial carcinomas with
MRI using traditional and novel MRI techniques. Clin
▪ Cervix slowly increases in volume under hormonal
Radiol. 67(1):2-12, 2012
stimulation until menopause 6. Zijta FM et al: Evaluation of the female pelvic floor in pelvic
◦ MR signal characteristics organ prolapse using 3.0-Tesla diffusion tensor imaging and
▪ T1WI: Homogeneously intermediate signal fibre tractography. Eur Radiol. 22(12):2806-13, 2012
intensity 7. Takeuchi M et al: Adenomyosis: usual and unusual imaging
▪ T2WI: Cervical zonal anatomy demonstrated manifestations, pitfalls, and problem-solving MR imaging
with T2WI; typical targetoid appearance on axial techniques. Radiographics. 31(1):99-115, 2011
8. Kyriazi S et al: Diffusion-weighted imaging of peritoneal
imaging disease for noninvasive staging of advanced ovarian cancer.
- Central mucus/secretions: Hyperintense
Radiographics. 30(5):1269-85, 2010
compared to myometrium 9. Colaiacomo MC et al: Dynamic MR imaging of the pelvic
- Endocervical epithelial lining: High signal floor: a pictorial review. Radiographics. 29(3):e35, 2009
intensity 10. Qayyum A: Diffusion-weighted imaging in the abdomen
- Inner cervical stroma: Hypointense compared to and pelvis: concepts and applications. Radiographics.
myometrium 29(6):1797-810, 2009
- Outer layer of smooth muscle: Intermediate 11. Saremi F et al: Characterization of genitourinary lesions
with diffusion-weighted imaging. Radiographics.
signal intensity 29(5):1295-317, 2009
▪ T1WI C+ FS: Endocervical mucosal lining enhances
12. Whittaker CS et al: Diffusion-weighted MR imaging of
to a greater degree than cervical stroma female pelvic tumors: a pictorial review. Radiographics.
▪ Fluid-signal nabothian cysts are commonly present 29(3):759-74; discussion 774-8, 2009
and may be multiple in number 13. Law YM et al: MRI of pelvic floor dysfunction: review. AJR
▪ DWI Am J Roentgenol. 191(6 Suppl):S45-53, 2008
- Endocervical mucosal lining appears 14. Parikh JH et al: MR imaging features of vaginal
hyperintense malignancies. Radiographics. 28(1):49-63; quiz 322, 2008
- Cervical stroma is hypointense
15. Sadowski EA et al: MR hysterosalpingography with an
angiographic time-resolved 3D pulse sequence: assessment
• Ovaries of tubal patency. AJR Am J Roentgenol. 191(5):1381-5, 2008
◦ Well-marginated adnexal ellipsoid organs containing 16. Elsayes KM et al: Vaginal masses: magnetic resonance
follicles in varied stages of development imaging features with pathologic correlation. Acta Radiol.
◦ Vary in size depending in age 48(8):921-33, 2007
▪ Premenarche: ~ 3 mL 17. Tamai K et al: MR features of physiologic and benign
▪ Premenopausal: ~ 10 mL conditions of the ovary. Eur Radiol. 16(12):2700-11, 2006
▪ Postmenopausal: ~ 6 mL 18. Brown MA et al: MRI of the female pelvis using vaginal gel.
◦ Location varies based on age and parturition
AJR Am J Roentgenol. 185(5):1221-7, 2005
19. Morakkabati-Spitz N et al: 3.0-T high-field magnetic
▪ Located in ovarian fossae in nulliparous patients
resonance imaging of the female pelvis: preliminary
▪ Variable in location in parous patients experiences. Eur Radiol. 15(4):639-44, 2005
▪ Ovaries can be located by following ovarian 20. Padhani AR et al: Perfusion MR imaging of extracranial
vasculature into pelvis tumor angiogenesis. Top Magn Reson Imaging. 15(1):41-57,
◦ MR signal characteristics 2004
▪ T2WI: Outer cortex has slightly decreased intensity, 21. Kido A et al: Diffusely enlarged uterus: evaluation with MR
whereas central medulla is of slightly higher signal imaging. Radiographics. 23(6):1423-39, 2003
22. Hamm B et al: MR imaging and CT of the female pelvis:
intensity radiologic-pathologic correlation. Eur Radiol. 9(1):3-15,
▪ T1WI: Homogeneous in signal, essentially
1999
isointense to myometrium 23. Kubik-Huch RA: Female pelvis. Eur Radiol. 9(9):1715-21,
▪ T1WI C+ FS: Ovarian parenchyma enhances to a 1999
lesser degree than myometrium
▪ Normal ovaries contain scattered follicles of fluid
signal intensity; corpus luteum may be present as
well
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Endometriomas Endometriomas
(Left) Axial T1WI MR shows
bilateral ovoid, hyperintense
ovarian masses . Given
the T1 hyperintensity, these
lesions my contain fat or
blood products. Note the
homogeneous intermediate
signal intensity of the
uterus . (Right) Axial
T1WI FS MR shows the
bilateral ovarian masses
remain hyperintense
upon fat suppression.
The T1 hyperintensity is
most indicative of blood
products related to ovarian
endometriomas.
Pelvic Floor Laxity Endometrial Carcinoma

(Left) Sagittal SSFP image
from a dynamic acquisition
obtained upon patient strain
(Valsalva maneuver) shows
abnormal middle compartment
descent . Note the
horizontal appearance of
the urethra and small
cystocele , consistent
with anterior compartment
involvement. (Right) Sagittal
T2WI MR shows abnormal
thickening and heterogeneity
of the endometrium in this
patient with biopsy-proven
endometrial carcinoma.
Endometrial Carcinoma Endometrial Carcinoma

(Left) Sagittal DWI from the
same patient shows the known
endometrial carcinoma
to be hyperintense. (Right)
Sagittal ADC image from the
same patient shows the known
endometrial carcinoma to
have low ADC signal. DWI and
ADC imaging can help in the
diagnosis and staging of pelvic
malignancy as well as provide
prognostic information and
measure response to therapy.
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Gartner Duct Cyst Leiomyomata
(Left) Sagittal T2WI shows a
well-marginated hyperintense
mass arising from the anterior
vaginal wall. Other sequences
showed this mass to follow
simple fluid signal and to be most
suggestive of a Gartner duct cyst.
(Right) Sagittal T2WI shows a
markedly enlarged uterus with
several myometrial masses
consistent with leiomyomata.
MR imaging can confidently
diagnose leiomyomata, evaluate
for degeneration, and monitor for
treatment response.
Septate Uterus Adenomyosis

(Left) Oblique axial T2WI shows
a retroflexed uterus with a
prominent fundal indentation
, consistent with a septate
uterus. MR imaging is ideally
suited for the characterization of
müllerian duct anomalies. (Right)
Sagittal T2WI shows thickening
of the junctional zone to involve
the entire myometrial wall.
There are small subendometrial
hyperintense foci , some of
which appear to communicate
with the endometrium. These
findings are diagnostic of
adenomyosis.
Ovarian Cancer Cervical Carcinoma

(Left) Oblique axial T1WI C+ FS
MR shows a complex cystic mass
arising from the right ovary
with enhancing mural nodularity
, suspicious for malignancy.
Note the hypoenhancing fibroid
within the uterine fundus.
(Right) Sagittal T2WI shows
loss of the normal hypointense
cervical stroma and an ill-defined
intermediate signal cervical
mass that invades the lower
uterine body. MR imaging is the
modality of choice in the staging
of cervical carcinoma.
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PET/CT TECHNIQUE AND IMAGING ISSUES
Techniques
Axial PET/CT image in a patient with a diagnosis of Axial PET/CT, same patient, shows a hypermetabolic
cervical carcinoma shows focal FDG-18 uptake within paraaortic lymph node < 1 cm in short axis diameter,
the cervix with a SUV(max) of 12.5. Due to limited representing metastatic nodal disease. PET/CT is most
spatial resolution, local staging with PET can be difficult. useful in detecting metastases or nodal involvement.
- Lymph node involvement is one of the most

TERMINOLOGY important prognostic factors in cervical cancer
Abbreviations - Probability of lymph node involvement increases
• Positron emission tomography (PET) with increasing SUV(max) of primary tumor
• - Disease-free survival rates are highly associated
Computed tomography (CT)
with nodal disease patterns
Synonyms ▪ Limited value in evaluation of local tumor extent,
• 18-fluorodeoxyglucose (FDG-18) PET/CT especially for small lesions
◦ FDG-18 is the most widely used tracer in clinical - MR is superior
practice; however, other tracers are available - Average SUV(max) values are generally higher
Definitions in squamous cell carcinomas (11.6) versus

•
adenocarcinomas (8.85) and adenosquamous
Imaging modality that combines functional/metabolic
tumors (8.05)
(PET) and anatomic (CT) information ▪ Pretreatment SUV(max) can serve as a marker for 5-
◦ PET imaging relies upon increased glucose uptake and
year survival
metabolism by malignant cells, though uptake can be - 95% for SUV(max) < 5.2
seen in benign tissues as well - 70% for SUV(max) between 5.2 and 13.3
- < 40% for SUV(max) > 13.3
PRE-PROCEDURE ▪ Response to treatment can be measured by changes
Indications in SUV(max); 3-year survival rates are related to
• Staging of pelvic malignancies metabolic responses
◦ Assesses nodal disease and metastatic spread - 70% for complete metabolic response (absence of
◦ Can contribute to local staging in cases of equivocal abnormal FDG-18 uptake)
- 16% for partial response
CT &/or MR findings
• - 13% for progressive disease
Evaluation of response to therapy
◦ Changes in metabolic activity as reflected by ▪ Can identify recurrent disease or metastases after
maximum standard uptake value (SUV[max]) precede treatment

- Routine use of PET/CT in surveilling
tumor shrinkage
• Restaging of pelvic malignancies, particularly if follow- asymptomatic patients is controversial
▪ Has added value in patients with recurrent cervical
up surgery is being considered
• Radiation therapy planning cancer who undergo salvage therapy, as PET/CT
◦ Planning radiotherapy target volume can provide precise restaging information
◦ Curative vs. palliative radiation therapy ◦ Endometrial carcinoma
• ▪ Primary indication is identification of metastases
Diagnosis-specific indications
◦ Cervical carcinoma or lymph node involvement
▪ Indicated in initial staging of FIGO stage IB or - Limited sensitivity in detecting metastatic lymph
higher tumors and in patients with positive nodes < 1 cm

▪ Evaluation of treatment response
paraaortic lymph nodes at surgery
▪ Detection of metastatic lymph nodes with better ▪ Detection of recurrent disease
◦ Vaginal and vulvar carcinoma
sensitivity and specificity than MR or CT alone
▪ Evaluation of extent of lymph node metastases
1 ◦ Ovarian carcinoma
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Key Facts
Terminology ◦ Physiological uptake in uterus and ovaries may
• Imaging modality that combines functional/metabolic simulate disease
◦ Nonneoplastic uptake can occur with infection,
(PET) and anatomic (CT) information
inflammation, post-therapy changes
Pre-Procedure ◦ Benign lesions may have mild FDG-18 uptake
• PET/CT is ideally suited for detection of nodal/ ◦ Hypermetabolic bowel serosal implants may be
metastatic disease for initial staging, restaging, and obscured by normal gut activity/uptake
surveillance imaging ◦ Normal bladder activity from excreted radiotracer
• Indications for gynecological PET/CT imaging may obscure pelvic disease
◦ Staging of pelvic malignancies ◦ Focal ureteric activity may simulate nodal disease
◦ Evaluation of response to therapy
◦ Restaging of pelvic malignancies
Procedure
◦ Radiation therapy planning • Low-dose NECT for attenuation correction
• Limitations/pitfalls of PET/CT • PET imaging is performed from caudad to cephalad
◦ Foci of disease < 1 cm may not be detected secondary • Subsequent diagnostic intravenous contrast-enhanced
to limited resolution of PET CT for coregistration and anatomic evaluation
▪ Useful in staging of advanced ovarian cancer and Advantages

surveillance for recurrent disease • Allows for precise localization of hypermetabolic
- Higher accuracy than with CT or PET alone
lesions utilizing detailed anatomic information
- High positive predictive value in diagnosis of
provided by CT
primary and recurrent ovarian cancer • Can identify small metastatic deposits difficult to see on
- Not typically used in primary diagnosis of
conventional imaging
ovarian malignancies; small but significant • Identifies metastatic disease in lymph nodes that are
number of false-negative and false-positive cases not pathologically enlarged
- Some borderline or low-grade tumors may not
• PET data can be corrected for photon attenuation using
have increased FDG-18 uptake CT scan to generate an attenuation map
▪ Can confirm local recurrence prior to pelvic
◦ Less statistical noise from CT compared with Ge-68
exenteration transmission data on stand-alone PET scanners
▪ Identifies patients with late recurrent disease who
◦ Due to fast CT data acquisition, PET/CT examination
may benefit from secondary cytoreductive surgery time is 15-20 minutes shorter than PET with
▪ Valuable when conventional studies are
radioactive source transmission correction
inconclusive or negative and tumor markers are ◦ More efficient use of fast-decaying PET
rising pharmaceuticals
▪ It is particularly useful for detecting tumor deposits
◦ Need for PET transmission hardware and cost of
in mesentery and bowel serosa replacing germanium source rods is eliminated
- Sensitivity in detecting small tumor implants (< 1
• CECT acquired in conjunction with PET/CT
cm) is limited examination offers a complete diagnostic imaging
◦ Other rare pelvic malignancies evaluation
▪ Fallopian tube carcinomas
• Standardized images can be transferred to a radiation
- Can help distinguishing between ovarian and
therapy planning system
fallopian tube cancers in setting of unknown
primary tumor Disadvantages
▪ Uterine sarcomas: Staging and follow-up • Utilization of ionizing radiation, with an increase in
▪ Uterine lymphoma: Staging and follow-up radiation dose compared to PET or CT performed alone
• Attenuation correction may be complicated by CT
Contraindications artifacts
• Pregnancy ◦ Use of concentrated CT contrast agents
• Breastfeeding ◦ Beam-hardening artifacts due to metallic implants
Getting Started ◦ Physiologic motion

• • Small lesions may not be identifiable on PET secondary
Things to check
◦ If iodinated intravenous contrast is administered for to limited spatial resolution
CT examination New Developments
▪ Renal function should be evaluated in at-risk
• PET/MR scanners are particularly useful in uterine
patients malignancies
▪ If patient takes metformin, appropriate precautions
• New tumor-specific radiotracers are becoming more
should be taken widely available
Patient Preparation
• Patients without insulin-dependent diabetes mellitus
(IDDM) should be instructed to 1
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◦ Abstain from food at least 4-6 hours prior to ▪ Used for coregistration with PET data and anatomic
procedure evaluation
◦ Drink plenty of water prior to procedure ▪ Typically performed similar to routine
• Patients with insulin-dependent diabetes mellitus abdominopelvic CT imaging protocols
(IDDM) should be instructed to
◦ Eat a high-protein meal ~ 4 hours prior to study and
Findings and Reporting
• Dedicated PET/CT workstation is mandatory for
take insulin as directed
◦ Drink plenty of water prior to procedure optimal viewing of coregistered scans
◦ Review CT data with appropriate window settings
• Patients should be comfortably warm prior to
◦ Examine displays of both attenuation-corrected and
procedure to reduce unwanted muscle activity and
physiological brown fat uptake non-attenuation-corrected PET data
◦ Review fused PET/CT data set to correlate
◦ Anxiolytics may be administered 1 hour prior to
imaging in order to reduce physiological brown fat hypermetabolic foci seen on PET with anatomic
uptake equivalent on CT
◦ PET/CT images can also be fused with available MR
▪ More helpful in head and neck imaging
• Consider placement of a urinary catheter to keep images
• Gynecological malignancies, peritoneal implants, and
bladder decompressed
◦ Reduces artifact of intense bladder activity from metastatic lymph nodes are FDG-18 avid
◦ Necrosis within tumor &/or lymph node can appear
excreted radiotracer
◦ Aids in visualization of small foci of disease in deep as photopenic area
◦ Low-grade tumors or those with low cellularity may
pelvis
have limited uptake
• Standardized uptake values (SUV) should be routinely
PROCEDURE
measured and reported
Procedure Steps ◦ It is generally accepted that SUV > 2-3 suggests
• Patient interview malignancy, while SUV < 2 is associated with benign
◦ Menstrual status lesions
◦ Phase of menstrual cycle if premenopausal ◦ In evaluating response to treatment, imaging is
◦ Premenopausal patients should be scheduled within ideally performed on same PET/CT scanner as initial
a week before or a few days after menses to minimize study and with an identical technique
physiologic endometrial uptake
• Patient positioning POST-PROCEDURE
◦ Patients are routinely imaged in supine position with
the arms raised above the head to prevent beam-
Things to Avoid
• Contact with young children for 10 hours following
hardening artifact on CT component of study
• Recommended imaging protocol injection of radiotracer
◦ Measurement of blood glucose level Specific Interpretation Issues
▪ Administration of rapid-acting insulin if glucose • Attenuation correction
level is above 200 mg/dL ◦ Overestimation of true FDG-18 activity with CT-
◦ Administration of 1 L dilute oral contrast agent 1
based attenuation correction due to overcorrection
hour before examination of photopenic areas secondary to high-attenuation
◦ Administration of 10-20 mCi (370–740 MBq) of
structures on CT
FDG-18, based on patient weight, 45-90 minutes ▪ Concentrated CT contrast agents
before examination ▪ CT beam-hardening artifact due to metallic
▪ Dose injected via an antecubital vein implants such as hip replacements, IUD, or surgical
▪ Note if extravasation occurs in order to clips
avoid confusion with pathological causes of ◦ Artifacts representing intense focal accumulation of
subcutaneous tracer uptake positive oral contrast material can be resolved by
◦ Bladder voiding just before examination to eliminate ▪ Viewing CT and non-attenuation-corrected PET
renally excreted FDG-18 images, which are not affected by high-density
◦ Low-dose CT with no IV contrast agent material
▪ Used for attenuation correction ▪ Use of diluted or negative-attenuation oral contrast
▪ Some advocate eliminating nonenhanced CT material
to reduce study time/radiation dose and using ◦ Coregistration with CECT data does not result
CECT for attenuation correction, though there are in significant artifacts following CT attenuation
increased attenuation artifacts correction
◦ PET starting at mid thighs and moving cephalad to • Misregistration
minimize pelvic image misregistration due to bladder ◦ False-positive or false-negative findings from
filling superimposition of FDG-18 activity on inappropriate
▪ Both PET and CT performed during shallow anatomic structures seen at CT
respiration ▪ Due to patient breathing, motion, bowel motility,
◦ Subsequent diagnostic intravenous contrast- distention of urinary bladder
enhanced CT
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◦ Normal "free" breathing (shallow breathing) is more ◦ Endometrial hyperplasia, benign ovarian tumors
suitable than maximum inspiratory or expiratory (dermoids), endometriosis, adenomyosis, benign
phases for acquisition of CT scans for coregistration reactive lymph nodes
▪ However, imaging upon breath-hold may be ◦ Leiomyomas may show increased uptake;
advantageous in terms of CT image quality hypermetabolic leiomyomas are more common in
◦ Minimizing time delay between PET and CT is premenopausal patients
important in reducing patient motion between scans • Hypermetabolic bowel serosal implants may be
obscured by normal gut activity/uptake
Pearls and Pitfalls • Normal bladder activity from excreted radiotracer may
• Metastatic deposits or lymph nodes < 1 cm may not obscure pelvic disease
be detected secondary to limited resolution of PET • Focal ureteric activity may simulate nodal disease
imaging
• Physiological uptake
◦ Uterus SELECTED REFERENCES
▪ Premenopausal endometrial FDG-18 uptake 1. Mirpour S et al: The role of PET/CT in the management of
changes cyclically, increasing during late cervical cancer. AJR Am J Roentgenol. 201(2):W192-205,
proliferative and early secretory phases and peaking 2013
near ovulation 2. Mitchell DG et al: ACR appropriateness criteria staging and
- Increased endometrial uptake may also be seen at follow-up of ovarian cancer. J Am Coll Radiol. 10(11):822-7,
2013
menstruation
▪ Patients with oligomenorrhea may have increased
3. Navve D et al: Physiological (18)F-FDG uptake patterns in
female reproductive organs before and after chemotherapy
endometrial uptake treatments: assessment by PET/CT. Med Oncol. 30(2):598,
▪ Increased endometrial FDG-18 uptake is abnormal 2013
in postmenopausal patients and suspicious for 4. Viswanathan C et al: Positron emission tomography-
malignancy computed tomography imaging for malignancies in women.
- Hormone replacement therapy should not result Radiol Clin North Am. 51(6):1111-25, 2013
in significantly increased endometrial uptake 5. Antunovic L et al: Revisiting the clinical value of 18F-
▪ Physiologic fallopian tube uptake can be seen at FDG PET/CT in detection of recurrent epithelial ovarian
carcinomas: correlation with histology, serum CA-125 assay,
menses and conventional radiological modalities. Clin Nucl Med.
◦ Ovary
37(8):e184-8, 2012
▪ Mild physiologic ovarian uptake can be seen in 6. Crivellaro C et al: 18F-FDG PET/CT can predict nodal
premenopausal patients metastases but not recurrence in early stage uterine cervical
▪ Focal unilateral ovarian FDG-18 uptake can be seen cancer. Gynecol Oncol. 127(1):131-5, 2012
within a corpus luteum 7. Langer JE et al: Imaging of the female pelvis through the life
- Corpus luteum cysts can be identified by typical cycle. Radiographics. 32(6):1575-97, 2012
8. Patel CN et al: 18F-FDG PET/CT of cervical carcinoma. AJR
CECT appearance: Small, crenelated, rim-
Am J Roentgenol. 196(5):1225-33, 2011
enhancing cyst 9. Son H et al: Role of FDG PET/CT in staging of recurrent
- SUV(max) values can exceed 3.0
ovarian cancer. Radiographics. 31(2):569-83, 2011
▪ Increased focal FDG-18 uptake in solid part of 10. Kitajima K et al: Spectrum of FDG PET/CT findings of
ovary that does not correspond to a corpus luteum uterine tumors. AJR Am J Roentgenol. 195(3):737-43, 2010
cyst on CT should be regarded as suspicious for 11. Prakash P et al: Role of PET/CT in ovarian cancer. AJR Am J
malignancy Roentgenol. 194(6):W464-70, 2010
▪ Postmenopausal ovarian FDG-18 uptake is 12. Son H et al: PET/CT evaluation of cervical cancer: spectrum
of disease. Radiographics. 30(5):1251-68, 2010
associated with malignancy
•
13. De Gaetano AM et al: Imaging of gynecologic malignancies
Nonneoplastic hypermetabolic lesions with FDG PET-CT: case examples, physiologic activity, and
◦ Granulomatous disease, infection/abscess,
pitfalls. Abdom Imaging. 34(6):696-711, 2009
postsurgical inflammation, radiation changes, 14. Suzuki R et al: Validity of positron emission tomography
foreign body reaction using fluoro-2-deoxyglucose for the preoperative evaluation
▪ CT imaging component can clarify/identify of endometrial cancer. Int J Gynecol Cancer. 17(4):890-6,
nonneoplastic conditions 2007
▪ Use of CECT can augment evaluation and avoid 15. Unger JB et al: The prognostic value of pretreatment 2-[18F]-
fluoro-2-deoxy-D-glucose positron emission tomography
false-positive interpretation
▪ Wait at least 6 weeks after surgical intervention for
scan in women with cervical cancer. Int J Gynecol Cancer.
17(5):1062-7, 2007
PET/CT if tumor recurrence is suspected in surgical 16. Blake MA et al: Pearls and pitfalls in interpretation
or irradiated bed of abdominal and pelvic PET-CT. Radiographics.
▪ Interpreting physicians should be aware of 26(5):1335-53, 2006
any pertinent clinical symptoms suggestive of 17. Kostakoglu L et al: PET-CT fusion imaging in differentiating
underlying inflammatory disease physiologic from pathologic FDG uptake. Radiographics.
◦ A small focus of increased endometrial uptake 24(5):1411-31, 2004
18. Lerman H et al: Normal and abnormal 18F-FDG
adjacent to a cervical carcinoma is not confirmatory
endometrial and ovarian uptake in pre- and
for endometrial invasion postmenopausal patients: assessment by PET/CT. J Nucl
▪ Increased uptake may be secondary to reactive
Med. 45(2):266-71, 2004
endometrial changes
• Benign lesions may have mild FDG-18 uptake
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Techniques
Axial Fused PET/CT, Cervical Carcinoma Coronal MIP PET, Cervical Carcinoma
(Left) Axial PET/CT from
an initial staging study in a
patient with a diagnosis of
cervical carcinoma shows
intense uptake within the
cervix , consistent with
the known malignancy.
No other abnormal sites of
uptake were noted. (Right)
Coronal MIP PET in the same
patient from a subsequent
restaging exam shows the
interval development of
multiple abnormal foci of
uptake , consistent with
metastatic disease. Note
the hypermetabolic left
supraclavicular node .
Axial CECT, Cervical Carcinoma Axial Fused PET/CT, Cervical Carcinoma

(Left) Axial CECT in the same
patient shows a small, subtle
soft tissue density serosal
implant within the anterior
right abdomen. This could
easily be overlooked on
routine anatomic imaging.
(Right) Axial PET/CT image in
the same patient at the same
level shows the serosal implant
to be hypermetabolic and
much easier to appreciate.
Axial CECT, Cervical Carcinoma Axial Fused PET/CT, Cervical Carcinoma

(Left) Axial CECT in the
same patient shows slight
asymmetry in size of the psoas
muscles , left greater than
right, without a well-defined
underlying mass. Note the
small paraaortic lymph node
. (Right) Axial PET/CT in
the same patient at the same
level shows a hypermetabolic
left psoas muscle mass ,
accounting for the asymmetric
size. Note that the small
paraaortic lymph node is
hypermetabolic, consistent
with nodal disease.
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Techniques
Coronal MIP PET, Axial Fused PET/CT,
Endometrial Carcinoma Endometrial Carcinoma
(Left) Coronal MIP PET in a
patient status post hysterectomy
and pelvic nodal dissection
for endometrial carcinoma
shows multiple abnormal foci
of uptake in the paraaortic
and periportal regions.
(Right) Axial PET/CT in the same
patient shows several enlarged
and hypermetabolic periportal
lymph nodes , consistent with
metastatic nodal disease.
Axial Fused PET/CT,

Axial CECT, Endometrial Carcinoma Endometrial Carcinoma
patient shows several enlarged
paraaortic lymph nodes .
(Right) Axial PET/CT image
from the same patient shows the
paraaortic lymph nodes to
be hypermetabolic, confirming
nodal spread of disease. PET/CT
can provide information about
disease extent that is essential for
treatment planning.
Axial Fused PET/CT, Cervical Carcinoma Axial CECT, Cervical Carcinoma

(Left) Axial PET/CT in a patient
with cervical carcinoma status
post resection and chemotherapy
shows a hypermetabolic aorto-
caval lymph node with a
SUV(max) of 4.4, representative
of a nodal metastasis. This was
the only site of abnormal uptake.
(Right) Axial CECT in the same
patient shows the small aorto-
caval lymph node , measuring
9 mm in short axis. Without the
metabolic information provided
by PET imaging, this may be
overlooked.
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SECTION 2
Uterus
Introduction and Overview

Uterine Anatomy 2-2
Age-Related Changes
Endometrial Atrophy 2-14
Congenital
Introduction to Müllerian Duct Anomalies 2-16
Uterine Hypoplasia/Agenesis 2-20
Unicornuate Uterus 2-26
Uterus Didelphys 2-32
Bicornuate 2-38
Septate Uterus 2-42
Arcuate Uterus 2-48
DES Exposure 2-50
Congenital Uterine Cysts 2-52
Asherman Syndrome, Endometrial Synechiae 2-54
Endometritis 2-58
Pyomyoma 2-62
Benign Neoplasms
Myometrium
Uterine Leiomyoma 2-66
Degenerated Leiomyoma 2-72
Parasitic Leiomyoma 2-80
Benign Metastasizing Leiomyoma 2-84
Diffuse Leiomyomatosis 2-86
Intravenous Leiomyomatosis 2-90
Disseminated Peritoneal Leiomyomatosis 2-94
Lipomatous Uterine Tumors 2-96
Obgyne Books Full

Endometrium
Endometrial Polyps 2-100
Endometrial Hyperplasia 2-106
Malignant Neoplasms
Myometrium
Adenosarcoma 2-110
Malignant Mixed Mesodermal Tumor 2-114
Uterine Leiomyosarcoma 2-120
Endometrium
Endometrial Carcinoma 2-124
Endometrial Stromal Sarcoma 2-142
Gestational Trophoblastic Disease 2-146
Vascular
Uterine Arteriovenous Malformation 2-162
Uterine Artery Embolization Imaging 2-168
Tamoxifen-Induced Changes 2-174
Contraceptive Device Evaluation 2-180
Post Cesarean Section Appearance 2-188
Adenomyosis
Adenomyosis 2-192
Adenomyoma 2-198
Cystic Adenomyosis 2-202
Obgyne Books Full

Uterus UTERINE ANATOMY
◦ Postmenopausal
GROSS ANATOMY ▪ Corpus atrophies to premenarchal size
Overview • Menstrual cycle
• ◦ Proliferative phase
Thick-walled, fibromuscular organ composed of
▪ End of menstruation to ovulation (~ day 14)
myometrium and endometrium
• ▪ Estrogen induces proliferation of functionalis layer
Flattened, inverted pear shape
• ▪ Corresponds to follicular phase of ovary
2 major anatomic divisions
◦ Body (corpus uteri) ◦ Secretory phase
▪ Fundus is portion of uterus above ostia of fallopian ▪ Ovulation to beginning of menstruation
▪ Progesterone induces endometrium to secrete
tubes
▪ Smooth, slightly convex fundal contour without glycogen, mucus, and other substances
▪ Endometrial glands become enlarged and tortuous
cleft
▪ Isthmus is the tapering of lower uterine segment at ▪ Corresponds to luteal phase of ovary
◦ Menstrual phase
▪ Cornua are lateral funnel-shaped horns of superior ▪ Sloughing of functionalis layer of endometrium
uterus Anatomic Relationships

◦ Cervix (cervix uteri)
• Uterus is extraperitoneal
• Myometrium ◦ Peritoneum extends over bladder dome and upper
◦ Interwoven layers of smooth muscle with connective
portion of anterior uterus
tissue and elastic fibers ▪ Lower portion of anterior uterus is not covered by
◦ Thickest at fundus, decreases in mass toward cervix
peritoneum
◦ Thin superficial serosal covering
▪ Creates anterior cul-de-sac (vesico-uterine pouch)
• Endometrium ◦ Posteriorly, peritoneum extends inferiorly to upper
◦ Mucosal lining of endometrial cavity
portion of vagina
◦ Single layer of ciliated columnar cells with multiple
▪ Creates posterior cul-de-sac (pouch of Douglas,
tubular glands recto-uterine pouch)
◦ 2 distinct components
▪ Most dependent portion of female pelvis
▪ Stratum functionalis: Superficial layer that
• Supporting ligaments
thickens under hormonal stimulation and sloughs ◦ Broad ligament
with menstruation ▪ Formed by the 2 layers of peritoneum contiguous
▪ Stratum basalis: Deep supporting mesenchymal
with uterine peritoneal covering
layer, densely adherent to myometrium ▪ Extends laterally to pelvic sidewall
• Cervix ▪ Forms supporting mesentery for uterus
◦ Originates at inferior narrowing of uterus (isthmus)
▪ Superior portion is the mesosalpinx; supports
▪ Has supravaginal and vaginal (ectocervix or portio
fallopian tube
vaginalis) portions ◦ Round ligaments
◦ Internal os: Opening into uterine cavity
▪ Arise from uterine cornu slightly inferior and
◦ External os: Opening into vagina
anterior to fallopian tubes
◦ Stroma is highly fibrous, with a high proportion of
▪ Course anteriorly and through inguinal canal to
elastic fibers interwoven with smooth muscle insert on labia majora
◦ Numerous endocervical glands drain into
◦ Cardinal (transverse cervical) ligaments
endocervical canal ▪ Thickened portions of base of broad ligament
▪ When obstructed/dilated, form nabothian cysts
▪ Extend laterally to pelvic sidewall
◦ Endocervical canal lined by single layer of ciliated
◦ Uterosacral ligaments: Extend from lateral uterus/
mucous-secreting columnar epithelium cervix to sacrum
▪ Epithelium organized in a series of small V-shaped
◦ Vesicouterine/vesicocervical ligaments: Extend from
folds (plicae palmatae) lateral margins of cervix and vagina to bladder
◦ Ectocervix lined by stratified squamous epithelium
• Uterine positioning
contiguous with vaginal mucosal lining ◦ Flexion describes positioning of uterine body relative
◦ Squamocolumnar junction near external os but exact
to cervix
position is variable, with continuous remodeling ▪ Most uteri are anteflexed
▪ Site of development of cervical carcinoma
◦ Version describes axis of cervix relative to vagina
• Appearance, size, and morphology of uterus vary with ▪ Most uteri are anteverted
age, estrogen stimulation, and parturition ◦ To avoid confusion, can describe uterus as
◦ Premenarche
"antepositioned" or "retropositioned"
▪ Cervix is larger than corpus (~ 2/3 of uterine mass)
◦ Retroverted/retroflexed uteri may be difficult to
▪ Uterus measures 2.5-3.5 cm in length
evaluate on US
◦ Menarche
• Fallopian tubes connect uterine cavity to peritoneal
▪ Preferential growth of corpus in response to
cavity
hormonal stimulation ◦ Attached to mesosalpinx (upper portion of broad
▪ In nulliparous women, corpus and cervix roughly
ligament)
equal, total 6-8 cm in length ◦ Originate from uterine cornua
▪ In parous nonpregnant women, corpus is ~ 2/3 of
◦ 8-14 cm in length
2 uterine mass, total 9-10 cm in length
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UTERINE ANATOMY
Uterus
◦ Covered by peritoneum, lined by single layer of ◦ Compacted, thin, hypoechoic inner layer forms
columnar cells subendometrial halo adjacent to endometrium
◦ Muscular layer with both circular and longitudinal ◦ Thicker, homogeneously echogenic middle layer
fibers, allows for peristalsis ◦ Thinner, hypoechoic outer layer
◦ Composed of 4 segments: Interstitial, isthmus, ▪ Portion of myometrium peripheral to arcuate
ampulla, and infundibulum vessels
◦ Interstitial (intramural) ◦ Arcuate vessels may be visible in outer 1/3 of
▪ Portion of tube that traverses uterine wall myometrium as tubular hypoechoic channels with
▪ ~ 1 cm in length internal Doppler flow
◦ Isthmus ▪ Vascular calcifications seen as linear shadowing
▪ Narrow portion of tube, immediately adjacent to echogenic foci in outer 1/3 of myometrium in
uterus postmenopausal patients
▪ 2-3 mm in diameter • Endometrium: Appearance varies with phase of
◦ Ampulla menstrual cycle
▪ Tortuous, ectatic portion contiguous with isthmus, ◦ Proliferative phase
5-8 mm in diameter ▪ Thin, echogenic line early
▪ Fertilization usually occurs in this portion of tube ▪ Progressive, hypoechoic thickening (4-8 mm) later
▪ Most common location for ectopic pregnancy in proliferative phase
◦ Infundibulum ▪ Trilaminar ("sandwich") appearance: Echogenic
▪ Funnel-shaped opening, ringed by finger-like central line created where the 2 hypoechoic
fimbriae endometrial walls coapt
▪ Opens into peritoneal cavity ◦ Secretory phase: After ovulation, endometrium
▪ Adjacent to posterior surface of ovary, allowing it to becomes thicker (7-14 mm) and more
"capture" ovulated ova homogeneously echogenic
• Uterus has dual arterial blood supply: Uterine and • Saline-infused sonohysterography
ovarian arteries ◦ Best suited to evaluate endometrial pathology
◦ Uterine artery variably arises as early branch of ◦ Balloon-tipped catheter inserted through cervix
anterior division of internal iliac artery ◦ Sterile saline infused with concurrent endovaginal
▪ Passes over ureter at level of cervix ("water under evaluation
the bridge") ▪ Separates endometrial walls, allowing for complete
▪ Runs within cardinal ligament evaluation of endometrium
▪ Courses superiorly along lateral margin of uterus • 3D ultrasound
and anastomoses with ovarian artery in broad ◦ Allows multiple views to be reconstructed from single
ligament sweep through uterus
◦ Uterine arteries give rise to arcuate arteries, which ◦ Useful in evaluating masses or IUD positioning
run in outer 1/3 of myometrium parallel to uterine
surface
MR
• T1WI: Uterus and cervix have uniform intermediate
◦ Radial arteries branch perpendicularly from
the arcuate arteries, extend through inner signal
• T2WI: Uterus has 3 distinct zones
myometrium, and terminate as spiral arteries to
◦ High-signal endometrium
supply endometrium
◦ Low-signal junctional zone
• Venous drainage
▪ Decreased T2 signal from lower water content and
◦ Myometrial veins follow same course as arteries
◦ Forms complex venous network in parametrium higher density of smooth muscle fibers
▪ Normal thickness: 2-8 mm
◦ Eventually drains to either uterine or ovarian vein in
▪ ≥ 12 mm abnormal (adenomyosis)
broad ligament
▪ 9-11 mm equivocal
• Lymphatic drainage
◦ Intermediate signal myometrium
◦ Largely follows venous vessels to drain to internal
◦ Prominent arcuate vasculature may appear as flow
iliac nodes
◦ Minor pathways include voids in outer 1/3 of myometrium
• Uterine appearance varies according to hormonal
▪ Direct drainage to external iliac or obturator nodes
▪ Along round ligaments to inguinal nodes stimulation/menstrual phase
◦ Premenarche: Uterine body is small and zonal
▪ Via ovarian lymphatics to paraaortic nodes
▪ Along uterosacral ligaments to presacral nodes anatomy is indistinct
◦ Premenopausal (postmenarche)
▪ Endometrium progressively thickens throughout
IMAGING ANATOMY
proliferative and secretory phases
Ultrasound ▪ Myometrial T2 signal increases in secretory phase
• Uterus evaluated with both transabdominal and from increased water content and vascular flow
endovaginal techniques ▪ Myometrium decreases in thickness and T2 signal
◦ Uterine size and large myometrial masses often better at menses, complicating evaluation of underlying
evaluated transabdominally lesions
◦ Endometrium best seen on endovaginal evaluation
• Myometrium: 3 layers usually discernible
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▪ Junctional zone does not significantly change

in thickness between proliferative and secretory
ANATOMY IMAGING ISSUES
phases but may be thickened &/or indistinct Imaging Recommendations
during menses • US is primary modality in evaluation of uterus
◦ Postmenopausal • MR can be used as a problem-solving tool or for more
▪ Endometrium atrophies
precise characterization
▪ Myometrium atrophies and T2 signal decreases ◦ Modality of choice in evaluation for adenomyosis
▪ Junctional zone may be difficult to visualize ◦ Evaluation of endometrium when obscured on US
◦ Oral contraceptives ◦ Superior in staging of uterine malignancies
▪ Thinned endometrium
▪ Junctional zone thins, may be indistinct Imaging Pitfalls
▪ Myometrium may have increased T2 signal • Knowledge of patient's menstrual status at time of study
• Uterine contractions are transient mass-like T2- is paramount
hypointense foci, which can distort uterine contour ◦ Endometrium/myometrium vary in appearance
◦ Persist for several minutes throughout cycle and can simulate pathology
◦ May be confused with fibroids or adenomyosis • Myometrial contractions can be misinterpreted as
◦ Disappear on subsequent sequences or cine imaging fibroids/adenomyosis but are transient
• Cervical zonal anatomy on T2WI
◦ Hyperintense central mucus/secretions in canal EMBRYOLOGY
◦ High-signal endocervical epithelial lining
▪ Plicae palmatae may be seen as a separate
Uterine Development
• Uterus and upper vagina arise from paired
intermediate-signal zone on high-resolution scans
◦ Low-signal inner cervical stroma, due to large paramesonephric (müllerian) ducts
◦ Form lateral to mesonephric duct between 6 and 7
proportion of fibrous and elastic tissue
▪ Contiguous with junctional zone of uterine corpus weeks of gestation
• Caudal aspect of paramesonephric ducts fuse at midline
◦ Outer layer of intermediate-signal smooth
◦ Fused inferior portion forms upper vagina and uterus
muscle may be variably present, contiguous with
◦ Unfused superior segments empty into peritoneal
myometrium
◦ Cervical zonal anatomy does not significantly change cavity, persist as fallopian tubes
◦ Fusion abnormalities lead to müllerian duct
in appearance throughout menstrual cycle
◦ Nabothian cysts are seen in > 50% of cases anomalies
▪ Represent obstructed, dilated cervical glands • Caudal end of fused paramesonephric ducts projects
▪ Typically asymptomatic, incidental findings into urogenital sinus
▪ Low signal on T1WI, high signal on T2WI, ◦ Lower vagina forms from urogenital sinus
nonenhancing, but can be variable in signal

• Parametrium RELATED REFERENCES
◦ Loose connective tissue between layers of broad
1. Yitta S et al: Normal or abnormal? Demystifying uterine
ligament along lateral margin of uterine body and cervical contrast enhancement at multidetector CT.
▪ Contains rich network of blood vessels and
Radiographics. 31(3):647-61, 2011
lymphatics 2. Sajjad Y: Development of the genital ducts and external
◦ Low to intermediate signal intensity on T1WI genitalia in the early human embryo. J Obstet Gynaecol Res.
◦ Variable signal intensity on T2WI 36(5):929-37, 2010
▪ Round ligament and uterosacral ligament low in 3. Takeuchi M et al: Manifestations of the female reproductive
signal intensity organs on MR images: changes induced by various
▪ Cardinal ligament and associated venous plexuses physiologic states. Radiographics. 30(4):1147, 2010
4. Hauth EA et al: MR imaging of the uterus and cervix in
are high in signal intensity healthy women: determination of normal values. Eur
CT Radiol. 17(3):734-42, 2007
•
5. Well D et al: Age-related structural and metabolic changes
Typically not preferred modality in uterine evaluation
in the pelvic reproductive end organs. Semin Nucl Med.
• NECT 37(3):173-84, 2007
◦ Uterus is homogeneously soft tissue density
6. Semelka R: Abdominal-Pelvic MRI. 2nd ed. Hoboken: Wiley,
◦ Hypodense endometrium may be faintly visible 2006
• CECT 7. Cunningham F: Williams Obstetrics. 22nd ed. New York:
◦ Myometrium shows variable contrast enhancement McGraw-Hill Professional, 2005
▪ May show subendometrial, diffuse myometrial, or 8. Hoad CL et al: Uterine tissue development in healthy
patchy heterogeneous enhancement women during the normal menstrual cycle and
▪ Hypoenhancing in postmenopausal patients
investigations with magnetic resonance imaging. Am J
Obstet Gynecol. 192(2):648-54, 2005
◦ Endometrium appears as hypodense central stripe,
9. Okamoto Y et al: MR imaging of the uterine cervix: imaging-
best measured on sagittal image pathologic correlation. Radiographics. 23(2):425-45; quiz
◦ Cervix demonstrates targetoid enhancement pattern 534-5, 2003
▪ Central secretions/fluid: Hypodense 10. Moore KL et al: The Developing Human: Clinically Oriented
▪ Inner cervical mucosa: Hyperdense Embryology. 6th ed. Philadelphia: Saunders, 1998
▪ Inner stroma: Hypodense 11. Callen P: Ultrasonography in Obstetrics and Gynecology.
▪ Outer stroma: Hyperdense 3rd ed. Philadelphia: Saunders, 1994
2 • May be useful in staging of uterine malignancies
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UTERINE ANATOMY
Uterus
UTERINE ANATOMY
Interstitial (intramural)
portion of fallopian tube
Fallopian tube
Endometrium
Inner and outer layer of
myometrium
Internal os
Round ligament
Endocervical canal Anterior cul-de-sac
External os
Bladder
Tubal branch of uterine

artery
Ovarian artery
Ascending trunk of uterine

artery
Arcuate artery
Ureter
Uterine artery
Uterine artery
Radial arteries
Descending trunk of uterine
artery
Spiral arteries
(Top) The uterus is composed of an outer smooth muscle myometrial layer and an inner glandular endometrial layer. The subendometrial smooth
muscle along the inner myometrium is more compacted and relatively hypovascular, corresponding to the junctional zone on imaging. (Bottom)
The uterine artery arises from the anterior division of the internal iliac artery. It courses anterior to the ureter and medially to the lateral margin of
the uterus. At the level of the cervix, it bifurcates into ascending and descending branches. The ascending branch forms the major blood supply
to the uterus and anastomoses with the ovarian artery, a branch of the aorta, in the broad ligament. Arcuate arteries course circumferentially
in the outer 1/3 of the myometrium, parallel to the uterine serosal surface, and give rise to the radial and spiral arteries, which supply the
endometrium.
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UTERINE EMBRYOLOGY; UTERINE VASCULATURE, MRA
Right common iliac artery

Aorta
Right internal iliac artery
Posterior division, right

internal iliac artery
Left internal iliac artery
Anterior division, right

internal iliac artery
Left uterine artery
Right uterine artery

Left external iliac artery
(Top) Illustration demonstrates the embryological development of the uterus. Note the partial fusion of the lower segments of the
paramesonephric (müllerian) ducts, which develop into the uterine body, cervix, and upper vagina. The upper unfused ductal segments develop
into the fallopian tubes. Disruption of this process may lead to müllerian duct anomalies. (Bottom) Oblique coronal MIP from a pelvic MRA
demonstrates normal uterine arterial anatomy. The uterine artery arises as the 1st branch of the anterior division of the internal iliac artery. The
uterine artery descends in the lateral pelvis, then turns medially to anastomose with branches of the ovarian artery in the broad ligament. The
normal ovarian artery is often difficult to visualize on routine angiographic imaging.
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UTERINE ANATOMY
Uterus
AGE-RELATED APPEARANCE OF UTERUS, US
Urinary bladder
Uterine body
Cervix
Urinary bladder
Cervix
Endometrium
Uterine body Vagina
Urinary bladder
Uterine body Vagina
Cervix
(Top) Transabdominal ultrasound in a premenarchal patient shows a normal appearance of the uterus. In a prepubertal patient, the cervix is
slightly larger than the uterine body, and the uterine zonal anatomy is difficult to appreciate. (Middle) In a postmenarchal, premenopausal
woman, the uterine body increases in size secondary to hormonal stimuli. The uterine body can be up to 2/3 of the uterine mass in a parous
woman. The uterine zonal anatomy is usually well visualized, though variable in appearance related to phase of menstrual cycle. (Bottom) In a
postmenopausal woman, the uterine body decreases in mass and is roughly equal in size to the cervix. The zonal anatomy is often difficult to
appreciate, and arcuate vascular calcifications can be seen as echogenic shadowing foci in the outer 1/3 of the myometrium.
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CYCLICAL APPEARANCE OF ENDOMETRIUM, US
Myometrium
Interface of coapted endometrial layers
Anterior and posterior proliferative

phase endometrial layers
Normal arcuate vasculature
Urinary bladder
Secretory phase endometrium

Myometrium
Cervix
Thinned, atrophic endometrium
Myometrium
(Top) Longitudinal endovaginal ultrasound of the uterus shows the classic trilaminar appearance of the early proliferative endometrium (calipers),
producing the "sandwich" appearance. The early proliferative endometrium is hypoechoic, with the intervening thin hyperechoic line produced
by the interface between the 2 endometrial layers. (Middle) Longitudinal endovaginal ultrasound of the uterus shows a typical appearance of
secretory-phase endometrium. The endometrium thickens and becomes more echogenic throughout the late proliferative and secretory phases
as it prepares for implantation of a fertilized ovum. (Bottom) Longitudinal endovaginal ultrasound of the uterus in a patient with postmenopausal
bleeding demonstrates a small, atrophic uterus. The endometrium is thinned, measuring < 2 mm, consistent with endometrial atrophy.
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UTERINE ANATOMY
Uterus
NORMAL ENDOMETRIUM, SIS; TUBAL ANATOMY, HYSTEROSALPINGOGRAM
Catheter balloon
Normal thin early proliferative phase
endometrium
Artifact from air in catheter balloon

Saline-distended endometrial cavity
Saline distended endometrial cavity
Normal thin early proliferative phase

endometrium
Uterine cornua
Posterior fundal myometrium
Right isthmic segment
Interstitial/intramural segments
Right ampullary segment

Left infundibular segment
Free spillage of contrast

Hysterosalpingogram catheter and
balloon
(Top) Longitudinal endovaginal image of the uterus obtained during a saline-infused sonohysterogram shows normal smooth, thin endometrium.
A SIS is performed in the early proliferative phase when the normal endometrium is uniformly thin. (Middle) Transverse endovaginal image
through the uterine fundus, obtained during a saline-infused sonohysterogram, shows normal uterine cornual contours. The endometrium is
uniformly smooth and thin. (Bottom) Frontal image from a fluoroscopic hysterosalpingogram demonstrates normal tubal anatomy. The fallopian
tubes are composed of 4 segments: Interstitial/intramural, isthmic, ampullary, and infundibular segments.
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UTERINE ZONAL ANATOMY, MR
Ovary
Endometrium
Junctional zone
Myometrium Cesarean section scar
Junctional zone
Endometrium
Myometrium
Endocervical canal
(Top) Sagittal T2WI MR through the uterus demonstrates normal zonal anatomy. The central endometrium is uniformly T2 hyperintense and
varies in thickness throughout the menstrual cycle. The junctional zone is a thin, well-defined, subendometrial T2-hypointense myometrial band.
The outer myometrium is relatively homogeneous and of intermediate signal intensity. Arcuate vasculature is often seen in the outer 1/3 of the
myometrium. (Bottom) Oblique axial T2WI MR through the uterus demonstrates the normal zonal anatomy. The junctional zone in this patient is
uniformly thin, without focal widening or areas of indistinctness. The central endometrium is uniformly T2 hyperintense and continuous with the
cervical mucosal lining. Note the mild septate uterine variant.
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UTERINE ANATOMY
Uterus
PREMENARCHAL AND POSTMENOPAUSAL UTERUS, MR
Uterine body
Distended urinary bladder Cervix
Myometrium
Endometrium
Urinary bladder,
decompressed Cervix
(Top) Sagittal T2WI MR through the pelvis demonstrates a normal premenarchal appearance of the uterus. The uterine body is small, roughly
the same size or smaller than the cervix. The normal uterine zonal anatomy is not well appreciated. (Bottom) Sagittal T2WI MR of the uterus in
a postmenopausal patient shows the normal age-related appearance of the uterus. In a premenarchal patient, the cervix and uterine body are
roughly the same size, whereas the uterine body predominates in the premenopausal/postmenarchal patient. The junctional zone is difficult to
discern, and the endometrium is uniformly thin.
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CERVICAL ZONAL ANATOMY, MR
Low signal inner cervical

stroma
Central high signal

secretions in endocervical
canal
Intermediate signal cervical

mucosa
Intermediate signal outer
cervical stroma
Outer cervical stroma
Inner cervical stromal layer
Cervical mucosa
External cervical os
Fluid in vaginal lumen
Secretions within
endocervical canal
(Top) Axial T2WI MR through the cervix shows the normal targetoid appearance of the cervix. Centrally, secretions within the endocervical canal
appear hyperintense. The cervical mucosal layer is of intermediate signal intensity. The inner cervical stroma is uniformly hypointense, whereas
the outer stromal layer demonstrates intermediate T2 signal intensity. (Bottom) Sagittal T2WI MR through the cervix demonstrates the normal
cervical zonal anatomy. The cervical mucosal layer is contiguous with the endometrium. The hypointense inner stromal layer is continuous with
the junctional zone, and the intermediate-signal outer stroma is continuous with the uterine myometrium.
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UTERINE ANATOMY
Uterus
UTERINE ANATOMY, CT
Central hypodense Myometrium

endometrium
Cesarean section scar

Cervix
Urinary bladder
Fundal myometrium
Endometrium
Thin subendometrial
enhancement
Cervix
(Top) Sagittal CECT through the pelvis shows a typical CT appearance of the uterus. The endometrial thickness is most reliably measured on
sagittal reconstructed images. The zonal anatomy of the uterus and cervix is not well demonstrated on CT. Note the focal thinning of the anterior
lower uterine segment myometrium, consistent with a C-section scar. (Bottom) Oblique axial CT through the pelvis shows a normal appearance
of the uterus. The endometrium appears uniformly hypodense and hypoenhancing. The normal myometrium can have a range of enhancement
patterns: Subendometrial (as in this case), homogeneous, and diffusely heterogeneous.
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Uterus ENDOMETRIAL ATROPHY
Key Facts
Terminology Top Differential Diagnoses
• Atrophy of endometrium in response to a • Endometrial polyp (cystic)
hypoestrogenic state • Endometrial hyperplasia (cystic)
Imaging Pathology
• Thin endometrium (< 5 mm) • Menopause (most common etiology)
• Smooth, uniform, echogenic endometrial stripe • Tamoxifen use
• ± cystic dilation of endometrial glands • Prolonged oral contraception
• "Spurious" widening secondary to cystic atrophy with • Atrophy can also be result of any condition that
cysts "projecting" into endometrial cavity induces a prolonged hypoestrogenic state
• Sonohysterography (SHG): Thin endometrium < 2.5 • In absence of estrogen, functional layer of
mm, no focal thickening or irregularity endometrium atrophies, leaving a thin basalis layer
• TVS should be initial modality for evaluation of and exposing vessels in underlying myometrium
endometrial cavity in symptomatic women
• If TVS is inconclusive or nondiagnostic (endometrial Clinical Issues
stripe not seen), SHG should be performed • Most common cause of postmenopausal bleeding
• Biopsies of endometria < 5 mm are highly unlikely to • Most patients are asymptomatic
be cancer & are often insufficient for diagnosis • Endometrial stripe < 5 mm essentially excludes cancer
(Left) Longitudinal transvaginal

ultrasound of the uterus in
a postmenopausal woman
shows a uniformly thin
echogenic endometrial stripe
, measuring 1 mm. (Right)
Transverse transvaginal
ultrasound in the same patient
shows the thin, uniformly
echogenic endometrial stripe
consistent with endometrial
atrophy, the most common
cause of postmenopausal
bleeding. Endometrial biopsy
is not necessary with a uniform
endometrial stripe < 5 mm
due to the very low risk of
endometrial cancer, even in
the setting of vaginal bleeding.
(Left) Sagittal T2WI MR shows

postmenopausal uterus
with a thin hyperintense
endometrium . (Right)
Sagittal transvaginal ultrasound
shows retroverted uterus with
thin endometrium and cystic
changes in the lower uterine
segment compatible with
cystic atrophy in this patient
receiving tamoxifen therapy.
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ENDOMETRIAL ATROPHY
Uterus
o Total ovarian functional insufficiency in certain
TERMINOLOGY
disease states (e.g., Sheehan & Schmidt syndromes)
Synonyms • Atrophy can also be result of any condition that
• Senile atrophy induces a prolonged hypoestrogenic state
Definitions
• In absence of estrogen, functional layer of
endometrium atrophies due to inactivity, leaving a
• Atrophy of endometrium in response to a thin basalis layer and exposing vessels in underlying
hypoestrogenic state myometrium
Gross Pathologic & Surgical Features
IMAGING • Atrophic mucosa: Pale, thin, and smooth
General Features • Measures ~ 4 mm in thickness
• Best diagnostic clue Microscopic Features
o Thin endometrium (< 5 mm)
o Smooth, uniform, echogenic endometrial stripe
• Atrophic mucosa: Scant small regular glands lined by a
single layer of small cylindrical cells
o ± cystic dilation of endometrial glands o Stroma is dense and composed of small round cells
▪ Subendometrial cysts often present in women on o Vascularization is poorly developed; arteriosclerotic
tamoxifen lesions are present
MR Findings o Intracavitary friction results in microerosion of
• Thin, smooth, uniform endometrium •
epithelium and chronic inflammatory reaction
• ± small cystic changes Cystic atrophy develops in longstanding
hypoestrogenic states
Ultrasonographic Findings o Obstruction of gland necks with subsequent dilation
• Grayscale ultrasound o Cystic spaces lined by atrophic endometrium with
o Thin echogenic endometrium < 5 mm (double-layer minimal fibrous stroma
thickness) o Located in endometrium or extend into endometrial-
o "Spurious" widening secondary to cystic atrophy with myometrial junction to form subendometrial cysts
cysts "projecting" into endometrial cavity
• Sonohysterography (SHG) CLINICAL ISSUES
o Thin endometrium < 2 mm (single layer thickness)
o No focal endometrial thickening or irregularity Presentation
o May see cystically dilated glands deep to endometrial • Most common signs/symptoms
surface o Postmenopausal bleeding (50-75% of cases)
o Most patients are asymptomatic
Imaging Recommendations
• TVS should be initial modality for evaluation of Natural History & Prognosis
endometrial cavity in symptomatic women • Atrophy is end result of prolonged hypoestrogenic state
• If TVS is inconclusive or nondiagnostic (endometrial • Good prognosis
stripe not seen), SHG should be performed • Endometrial stripe < 5 mm essentially excludes cancer
• If SHG is not available or cannot be performed because
of cervical stenosis, MR can be performed to exclude Treatment
large endometrial mass • Hormone replacement therapy
• Biopsies of endometria < 5 mm are highly unlikely to be
cancer and are often insufficient for diagnosis
DIAGNOSTIC CHECKLIST
DIFFERENTIAL DIAGNOSIS Image Interpretation Pearls
• Thin uniform endometrium ± cystically dilated glands
Endometrial Polyp (Cystic)
• Mass with cystic change within endometrial canal
• Sonohysterography confirms diagnosis SELECTED REFERENCES
1. Doubilet PM: Diagnosis of abnormal uterine bleeding with
Endometrial Hyperplasia (Cystic) imaging. Menopause. 18(4):421-4, 2011
• Cystic dilation of endometrial glands with thickening 2. Dubinsky TJ: Value of sonography in the diagnosis of
of endometrial stripe abnormal vaginal bleeding. J Clin Ultrasound. 32(7):348-53,
2004
3. Smith-Bindman R et al: How thick is too thick? When
PATHOLOGY endometrial thickness should prompt biopsy in
postmenopausal women without vaginal bleeding.
General Features Ultrasound Obstet Gynecol. 24(5):558-65, 2004
• Etiology 4. Ferenczy A: Pathophysiology of endometrial bleeding.
o Menopause (most common etiology) Maturitas. 45(1):1-14, 2003
o Surgical or radiotherapeutic castration 5. Goldstein RB et al: Evaluation of the woman with
o Tamoxifen use postmenopausal bleeding: Society of Radiologists in
Ultrasound-Sponsored Consensus Conference statement. J
▪ 17% of women in 1 study had cystic atrophy
o Prolonged oral contraception
Ultrasound Med. 20(10):1025-36, 2001
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Uterus INTRODUCTION TO MÜLLERIAN DUCT ANOMALIES
Key Facts
Terminology o High-resolution fast spin-echo T2-weighted images
• Congenital uterine anomalies result from abnormal parallel to long axis of uterus, ≤ 4 mm slice thickness
formation, fusion, or resorption of müllerian Pathology
(paramesonephric) ducts during fetal life
• Majority considered to be sporadic or multifactorial in
Imaging nature
• Hysterosalpingography (HSG) • 3-stage approach is used to simplify embryologic
o Does not allow evaluation of external uterine fundal development: Ductal development, ductal fusion, and
septal reabsorption
•
contour
• Ultrasound
Associated anomalies
o Ovarian maldescent
o Significant limitations remain in diagnosing
o Renal anomalies
müllerian duct anomalies (MDA) subtypes, o Obstructed hemivagina
•
including identification of unicornuate uterus and
Classification of MDA
rudimentary uterine horns
o Initially proposed by Buttram and Gibbons
• MR
o Modified in 1988 by subcommittee of American
o Reported accuracy of up to 100%
o Ideal imaging modality for evaluation of MDAs Fertility Society (now American Society of
Reproductive Medicine)
Class I anomalies consist of segmental agenesis and variable degrees of uterovaginal hypoplasia. Class II anomalies are unicornuate uteri that
represent partial or complete unilateral hypoplasia. Class III is composed of uterus didelphys in which duplication of the uterus results from
complete nonfusion of the müllerian ducts. Class IV anomalies are bicornuate uteri that demonstrate incomplete fusion of the superior segments
of the uterovaginal canal. Class V anomalies are septate uteri that represent partial or complete nonresorption of the uterovaginal septum. Class
VI anomalies are arcuate uteri that result from near-complete resorption of the septum. Class VII anomalies result from in utero DES exposure.
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INTRODUCTION TO MÜLLERIAN DUCT ANOMALIES
Uterus
o Hysterosonography, with infusion of saline into
TERMINOLOGY
endometrial canal, provides improved delineation of
Abbreviations endometrium and internal uterine morphology
• Müllerian duct anomalies (MDAs) ▪ Shares same limitations of conventional
endovaginal US
Definitions ▪ Can only help evaluate patent endometrial canals
• Congenital uterine anomalies result from abnormal o Imaging should include orthogonal images along
formation, fusion, or resorption of müllerian long axis of uterus to characterize external uterine
(paramesonephric) ducts during fetal life contour
o 3D US with surface and transparent-mode
IMAGING reconstructions of uterus has reported advantages
over conventional 2D scanning
Imaging Techniques ▪ Allows improved delineation of external uterine
• Hysterosalpingography (HSG) has traditionally been contour
used for evaluation of MDA •Advantages
o Typically indicated in initial stages of infertility work- o Does not require ionizing radiation
up o Widely available
• US and MR imaging play important roles in diagnosis o Rapid
and evaluation of suspected MDA
o Both modalities provide greater anatomic detail
•Limitations
o Significant limitations remain in diagnosing MDA
▪ Detailed information of external uterine contour, subtypes, including identification of unicornuate
which is an important diagnostic feature of MDAs uterus and rudimentary uterine horns
o Assess for concomitant renal anomalies o Operator dependent
▪ Renal anomalies occur at higher rate among MDA o May be limited due to patient's body habitus, uterine
patients lie, and shadowing from peristaltic bowel loops
HSG •Accuracy
o US has reported pooled accuracy of approximately
• Allows for assessment of uterine cavity and tubal
90–92%
patency
o In experienced hands, 3D US has sensitivity of 93%
• Technique
o Performed under fluoroscopy; catheter is placed into and specificity of 100%
cervical canal, and balloon is inflated to prevent MR
contrast leakage
o Water-soluble contrast material is then slowly
• Advantages
o Ideal imaging modality for evaluation of MDAs
introduced into uterine cavity, with select ▪ Provides clear anatomic detail of both internal
fluoroscopic spot images obtained to evaluate uterine uterine cavity and external contour
configuration, uterine filling defects, and fallopian ▪ Complex anomalies and secondary diagnoses such
tube patency as endometriosis can be optimally characterized
• Disadvantages o Does not require ionizing radiation
o Presence of divided rather than triangular uterine
•Limitations
cavity suggests presence of MDA o More expensive than US
▪ Not possible to differentiate between different ▪ Diagnostic laparoscopy, routinely used when HSG
subtypes based merely on shape of uterine cavity and US were only available imaging modalities, is
o Does not allow evaluation of external uterine fundal
more expensive and invasive
contour
o Allows evaluation of only the component of uterine •Accuracy
o Reported accuracy of up to 100%
cavity that communicates with cervix
▪ In patient with double cervix, cannulation •Protocol
o Patients are best imaged with phased-array MR
of 1 cervix → opacification of 1 uterine horn
surface coil
→ erroneous diagnosis of uterus didelphys as o Inversion-recovery or gradient-echo image of uterus
unicornuate uterus
in sagittal plane is obtained initially to determine
Ultrasound uterine lie
• Timing of examination ▪ Important to obtain images through long axis
o During late secretory phase of menstrual cycle when of uterus immediately after localizing image is
endometrium is thicker and more echogenic acquired, otherwise urinary bladder filling may
• Technique change position of uterus
o T2-weighted transverse, coronal, and sagittal fast
o Transabdominal US is usually best performed
with curved 4–1 MHz or 6–3 MHz transducer, and spin-echo sequences
endovaginal US should be performed with 8–5 MHz ▪ Short-axis view of vagina to delineate vaginal
endovaginal transducer septum/duplication
o Endovaginal US has improved spatial resolution at o High-resolution fast spin-echo T2-weighted images
expense of decreased field of view parallel to long axis of uterus, ≤ 4 mm slice thickness
▪ To characterize external uterine contour
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Uterus INTRODUCTION TO MÜLLERIAN DUCT ANOMALIES
▪ Typically obtained in oblique transverse or coronal o Modified in 1988 by subcommittee of American

plane, depending on uterine lie Fertility Society (now American Society of
o T1-weighted transverse fast spin-echo sequence Reproductive Medicine)
▪ To confirm blood products in obstructed segments o Most notable inherent deficiency of classification
o Newer 3D T2-weighted sequences provide is related to description of anomalies that include
submillimeter section thickness along with features of ≥ 2 classes
multiplanar reformatting capability ▪ These anomalies should be described according
▪ Significantly reduces imaging time to their component parts and should not
– Particularly important in pediatric and sedated be categorized into class that most closely
or anesthetized patients approximates dominant feature
▪ Avoids need for exact prescription of imaging • Classes of MDAs
plane, since this can be performed retrospectively o Class I
at workstation ▪ Segmental agenesis and variable degrees of
o Finally, coronal fast spoiled-gradient-echo image uterovaginal hypoplasia
or single-shot fast spin-echo T2-weighted image is o Class II
obtained by using body coil with large field of view to ▪ Unicornuate uteri that represent partial or
enable assessment of kidneys complete unilateral hypoplasia
o Contrast material is generally reserved for assessment o Class III
of incidentally discovered additional disease ▪ Uterus didelphys in which duplication of uterus
CT results from complete nonfusion of müllerian
• No role for CT in evaluation of MDAs ducts
o Class IV
o Many cases are incidentally discovered on CT
▪ Bicornuate uteri that demonstrate incomplete
examination obtained for other reasons fusion of superior segments of uterovaginal canal
o Occasionally, exact diagnosis can be reached with o Class V
utilization of multiplanar reformats ▪ Septate uteri that represent partial or complete
nonresorption of uterovaginal septum
PATHOLOGY o Class VI
▪ Arcuate uteri that result from near-complete
General Features resorption of septum
• Etiology o Class VII
o Majority considered to be sporadic or multifactorial ▪ Sequelae of in utero DES exposure
in nature • Secondary classification systems also have been
▪ However, polygenic and genetic patterns of introduced that further dissect and elaborate on
inheritance have been described in expression of original Buttram and Gibbons schema
these anomalies
o Extrauterine and intrauterine environmental factors, Embryology
such as exposure to ionizing radiation, intrauterine • 3-stage approach is used to simplify embryologic
infections, and drugs with teratogenic effects, such development: Ductal development, ductal fusion, and
as thalidomide and diethylstilbestrol (DES), can also septal reabsorption
o Ductal development
cause defects of developing fetal genital tracts
▪ During first 6 weeks of development, male and
• Associated abnormalities
female fetuses are indistinguishable
o Ovarian maldescent is seen in 17% of women with
– Both demonstrating paired mesonephric
uterine anomalies, compared with 3% of women
(wolffian or male genital) ducts and
with normal uterine anatomy
o Renal anomalies paramesonephric (müllerian or female genital)
ducts
▪ Most common is absent unilateral kidney (31.8%)
▪ Presence of Y chromosome is associated with
▪ Other anomalies include ectopic kidney, horseshoe
production of müllerian-inhibiting factor (MIF)
kidney, renal dysplasia, and duplicated collecting
▪ After 6 weeks gestation, absence of MIF in female
systems
o Obstructed hemivagina fetus promotes bidirectional growth of paired
müllerian ducts in conjunction with simultaneous
Staging, Grading, & Classification regression of wolffian ducts
• Most widely accepted classification of MDAs was ▪ Interruption of müllerian duct development
proposed by Buttram and Gibbons during this time → aplasia or hypoplasia of
o Based on degree of failure of normal development upper vagina, cervix, or uterus
o MDAs were separated into classes that demonstrate o Ductal fusion
similar clinical manifestations, treatment, and ▪ Müllerian duct growth is accompanied by midline
prognosis for fetal salvage migration and fusion of these paired ducts to form
uterovaginal primordium
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INTRODUCTION TO MÜLLERIAN DUCT ANOMALIES
Uterus
▪ Interruption of müllerian duct fusion process • Evaluate for number of cervices
→ bicornuate and didelphys uterus • Evaluate vagina for vertical or transverse septa
o Septal reabsorption
▪ Between 9 and 12 weeks gestation, fused müllerian
• Evaluate kidneys for absence or other congenital
anomalies
ducts undergo process of reabsorption of
intervening uterovaginal septum
▪ Interruption of müllerian duct development SELECTED REFERENCES
during this reabsorption phase → septate or 1. Ludwin A et al: Two- and three-dimensional
arcuate uterus ultrasonography and sonohysterography versus
– Reabsorption process is thought to occur in both hysteroscopy with laparoscopy in the differential diagnosis
cranial and caudal directions of septate, bicornuate, and arcuate uteri. J Minim Invasive
– Bidirectional reabsorption model is more Gynecol. 20(1):90-9, 2013
2. Allen JW et al: Incidence of ovarian maldescent in women
congruent (than previously suggested with mullerian duct anomalies: evaluation by MRI. AJR Am J
unidirectional model) with some forms of MDA Roentgenol. 198(4):W381-5, 2012
such as isolated vaginal septum 3. Behr SC et al: Imaging of müllerian duct anomalies.
Radiographics. 32(6):E233-50, 2012
4. Faivre E et al: Accuracy of three-dimensional
CLINICAL ISSUES ultrasonography in differential diagnosis of septate and
bicornuate uterus compared with office hysteroscopy and
Presentation
• Most common signs/symptoms
pelvic magnetic resonance imaging. J Minim Invasive
Gynecol. 19(1):101-6, 2012
o Depends on subtype of MDA 5. Chan YY et al: The prevalence of congenital uterine
o Amenorrhea anomalies in unselected and high-risk populations: a
o Inability to conceive or repeated pregnancy losses systematic review. Hum Reprod Update. 17(6):761-71, 2011
▪ Increased rate of miscarriage, preterm delivery, and 6. Troiano RN et al: Mullerian duct anomalies: imaging and
other adverse fetal outcomes clinical issues. Radiology. 233(1):19-34, 2004
o Cyclical pelvic pain due to outflow obstruction of 7. The American Fertility Society classifications of adnexal
adhesions, distal tubal occlusion, tubal occlusion secondary
associated endometriosis to tubal ligation, tubal pregnancies, müllerian anomalies
Demographics and intrauterine adhesions. Fertil Steril. 49(6):944-55, 1988
• Age 8. Buttram VC Jr et al: Müllerian anomalies: a proposed

classification. (An analysis of 144 cases). Fertil Steril.
o Age of presentation depends on subtype of MDA 32(1):40-6, 1979
▪ Primary amenorrhea at age of menarche
▪ Inability to conceive, repeated pregnancy losses,
and cyclical pelvic pain during reproductive years
• Epidemiology
o Reported prevalence of MDA varies widely in
literature
▪ ~ 5.5% in general population
▪ ~ 8% in infertile women
▪ ~ 13.3% in women with history of miscarriage
▪ ~ 24.5% among women who have experienced
miscarriage and infertility
o Most common anomalies in general population
▪ Arcuate uterus (3.9% of women)
▪ Bicornuate uterus (0.4% of women)
o Most common anomalies among women with
difficulty conceiving (e.g., infertility or miscarriage)
▪ Septate uterus, affecting 15.4% of women with
impaired fertility
Treatment
• Varies according to specific type of malformation and
discussed under each entity
Image Interpretation Pearls
• Appearance of external uterine fundal contour is most
important finding in differentiating different subtypes
of MDA
o Convex, flat, or cleft < 1 cm → resorption anomaly
(septate or arcuate)
o Cleft > 1 cm → fusion anomaly (didelphys or
bicornuate)
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Uterus UTERINE HYPOPLASIA/AGENESIS
Key Facts
Terminology • Limited role of CT and US in evaluation of uterine
• Müllerian agenesis, uterovaginal agenesis hypoplasia or agenesis
• MR is most useful modality for evaluation of müllerian
• Class I müllerian duct anomaly based on Buttram remnants (uterine buds)
and Gibbons and American Society for Reproductive
Medicine revision Top Differential Diagnoses
• Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome • Gonadal dysgenesis
o Extreme presentation of müllerian agenesis with
• Androgen insensitivity syndrome
absence of proximal vagina, cervix, and uterus
• Pseudohermaphrodite (male)
Imaging Clinical Issues
• Depends on degree of hypoplasia or agenesis of • Incidence 1:4,000
• ~ 5-10% of müllerian duct anomalies (MDAs)
müllerian segments
• Typical müllerian remnants in MRKH syndrome
consist of 3 structural components • Primary amenorrhea
o Midline triangular soft tissue • Cyclic pelvic pain
o Bilateral uterine buds (rudimentary uteri) • Vaginal dilatation or reconstruction
o Fibrous band-like structures • Surgical resection of uterine masses with functional
endometrium
Graphic illustrates the different types of morphologies resulting from müllerian agenesis or hypoplasia. Developmental failure of the müllerian
ducts results in agenesis or hypoplasia of any or all portions of the proximal 2/3 of the vagina, cervix, and uterus. Isolated absence of the upper
vagina, cervix, uterus, or fallopian tubes may occur. Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is the extreme presentation of müllerian
agenesis with absence of the proximal vagina, cervix, and uterus.
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UTERINE HYPOPLASIA/AGENESIS
Uterus
o Most useful modality for evaluation of müllerian
TERMINOLOGY
remnants (uterine buds)
Synonyms ▪ Allows evaluation of vaginal remnant for future
• Müllerian agenesis, uterovaginal agenesis reconstruction surgery
▪ Allows evaluation of uterine buds for evidence of
Definitions functioning endometrium
• Class I müllerian duct anomaly based on Buttram – 1 or 2 rudimentary uteri can be identified in 92%
and Gibbons and American Society for Reproductive of patients
Medicine revision – Different degrees of differentiation into uterine
• Early developmental failure of müllerian ducts → zonal layers can be seen
agenesis or various degrees of hypoplasia of proximal – Cavity containing blood can occasionally be
2/3 of vagina, cervix, and uterus seen
• Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome
Ultrasonographic Findings
o Extreme presentation of müllerian agenesis with
absence of proximal vagina, cervix, and uterus • Technique
o 2 types have been described o Transvaginal imaging is often inappropriate or
▪ Typical MRKH (type I) impossible in this age group
– Isolated agenesis of uterus and vagina ▪ Transrectal and transperineal sonography have
▪ Atypical MRKH (type II) or MURCS (müllerian duct been used
aplasia, renal aplasia, and cervicothoracic somite) – Transrectal ultrasound is not well tolerated by
syndrome young patients
o 3D US is of limited value in MRKH syndrome as there
are no structures to reformat
IMAGING • Limited role in evaluation of uterine agenesis/
General Features hypoplasia
o Can show normal ovaries
• Best diagnostic clue o Hematometra in patients with cervical agenesis
o Depends on degree of hypoplasia or agenesis of
▪ Distended uterus filled with echogenic blood
müllerian segments
▪ Isolated cervical agenesis Imaging Recommendations
– Distended, blood-filled uterus • Best imaging tool
– Absent or cord-like atretic cervix o US is usually initial examination showing absent
▪ MRKH uterus
– Midline uterine remnant ▪ Also to screen for associated renal tract
– Bilateral uterine buds abnormalities and to locate ovaries
– Normal ovaries o MR is modality of choice for complete mapping of
– Absent upper 2/3 of vagina anatomy
• Morphology
o Varies depending on which segments are involved
and degree of hypoplasia or aplasia
DIFFERENTIAL DIAGNOSIS
o Typical müllerian remnants in MRKH syndrome Gonadal Dysgenesis
consist of 3 structural components
▪ Midline triangular soft tissue
• Hypoplastic uterus with atrophic vagina
– Lying above bladder dome • Streak gonads
▪ Bilateral uterine buds (rudimentary uteri) Androgen Insensitivity Syndrome
– Usually symmetrical • Androgen insensitivity
– May have zonal anatomy
▪ Fibrous band-like structures
• Absent uterus, upper 2/3 vagina, ovaries
• Testes (usually undescended)
– Connect bilateral uterine buds and converge at
midline triangular soft tissue • Male karyotype (46,XY)
Hysterosalpingography (HSG) Pseudohermaphrodite (Male)
• No role in evaluation of uterine hypoplasia or agenesis • Variable development of uterus, upper 2/3 vagina
• Partial masculinization of external genitalia
CT Findings • Male karyotype (46,XY)
• Difficult to evaluate pelvic structures on CT
• Can be initial study in patients presenting with pelvic DES Exposure
• Hypoplastic uterus with T-shaped endometrial cavity
pain due to hematometra
o Midline high-density fluid-filled structure represents • Myometrial constriction bands
distended uterine cavity • Vagina present
MR Findings Total Hysterectomy
• T1WI FS • Absent uterus
o Hematometra presents as high signal intensity fluid • Vagina present with normal zonal anatomy
within endometrial cavity
• T2WI 2
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PATHOLOGY • Surgical resection of uterine masses with functional

endometrium
General Features
• Genetics DIAGNOSTIC CHECKLIST
o MRKH syndrome
▪ Polygenic multifactorial inheritance with a 1-2% Consider
recurrence risk • Uterine hypoplasia/agenesis as a cause of primary
▪ In familial cases, syndrome transmitted as amenorrhea in a young woman with normal secondary
autosomal dominant with incomplete penetrance sexual characteristics
and variable expressivity
▪ Associated with HNF1B gene mutations in Image Interpretation Pearls
conjunction with renal anomalies and diabetes • Absent or hypoplastic uterus ± agenesis of upper 2/3 of
o 46,XX female karyotype vagina
o MURCS syndrome SELECTED REFERENCES
▪ Renal malformations: Aplasia, ectopia, fusion
1. Committee on Adolescent Health Care: Committee
abnormalities opinion: no. 562: müllerian agenesis: diagnosis,
▪ Vertebral malformations, such as spina bifida and management, and treatment. Obstet Gynecol.
transitional lumbosacral or cervical vertebrae 121(5):1134-7, 2013
(Klippel–Feil syndrome) 2. Hall-Craggs MA et al: Mayer-Rokitansky-Kuster-Hauser
▪ Cardiac malformations and neurological syndrome: diagnosis with MR imaging. Radiology.
disturbances are rare 269(3):787-92, 2013
▪ Conductive or sensorineural hearing loss 3. Kara T et al: MRI in the diagnosis of Mayer-Rokitansky-
Kuster-Hauser syndrome. Diagn Interv Radiol. 19(3):227-32,
2013
CLINICAL ISSUES 4. Rousset P et al: Ultrasonography and MRI features of the
Mayer-Rokitansky-Küster-Hauser syndrome. Clin Radiol.
Presentation 68(9):945-52, 2013
• Most common signs/symptoms 5. Yoo RE et al: Magnetic resonance evaluation of Müllerian
o Primary amenorrhea remnants in Mayer-Rokitansky-Küster-Hauser syndrome.
Korean J Radiol. 14(2):233-9, 2013
▪ MRKH syndrome is 2nd most common cause of
6. Behr SC et al: Imaging of müllerian duct anomalies.
primary amenorrhea after gonadal dysgenesis Radiographics. 32(6):E233-50, 2012
o In setting of isolated partial vaginal or cervical 7. Fiaschetti V et al: Mayer-Rokitansky-Kuster-Hauser
agenesis and a normal uterine cavity or in setting of syndrome diagnosed by magnetic resonance imaging.
uterine mass with functional endometrium, patients Role of imaging to identify and evaluate the uncommon
may also present cyclic pelvic pain variation in development of the female genital tract. J Radiol
▪ Due to hematometra or endometriosis Case Rep. 6(4):17-24, 2012
• Clinical profile 8. Giusti S et al: Diagnosis of a variant of Mayer-Rokitansky-
Kuster-Hauser syndrome: useful MRI findings. Abdom
o Main characteristics of the syndrome
Imaging. 36(6):753-5, 2011
▪ Absence or reduced development of uterus and 9. Lermann J et al: Comparison of different diagnostic
upper 2/3 of vagina procedures for the staging of malformations associated with
– Little or no reproductive potential Mayer-Rokitansky-Küster-Hauser syndrome. Fertil Steril.
▪ Normal ovarian function 96(1):156-9, 2011
– Secondary sexual characteristics present 10. Pompili G et al: Magnetic resonance imaging in the
▪ Normal external genitalia preoperative assessment of Mayer-Rokitansky-Kuster-Hauser
▪ Normal female karyotype (46,XX) syndrome. Radiol Med. 114(5):811-26, 2009
11. Govindarajan M et al: Magnetic resonance imaging
Demographics diagnosis of Mayer-Rokitansky-Kuster-Hauser syndrome. J
• Epidemiology 12.
Hum Reprod Sci. 1(2):83-5, 2008
Morcel K et al: Mayer-Rokitansky-Kuster-Hauser (MRKH)
o Incidence 1:4,000
syndrome. Orphanet J Rare Dis. 2:13, 2007
o ~ 5-10% of müllerian duct anomalies 13. Pittock ST et al: Mayer-Rokitansky-Kuster-Hauser anomaly
and its associated malformations. Am J Med Genet A. 2005
Natural History & Prognosis
• Little or no reproductive potential
14. Fedele L et al: Magnetic resonance imaging in Mayer-
Rokitansky-Kuster-Hauser syndrome. Obstet Gynecol.
76(4):593-6, 1990
Treatment
• In patients with associated vaginal agenesis, vaginal
dilatation or reconstruction performed to allow normal
sexual functioning
o Vaginal dilatation (Frank method)
o Skin graft (McIndoe procedure)
o Laparoscopic creation of neovagina (modified
Vecchietti technique)
o Construction of neovagina with segment of sigmoid
2 colon (sigmoid colpoplasty)
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Uterus
(Left) Axial CECT in a 15-year-old
girl with normal external genitalia
who presented with severe
pelvic pain shows a midline
fluid-filled cystic structure .
(Right) Sagittal CECT in the
same patient shows the midline
cystic structure connected
to a band-like structure .
There is also fluid in the cul-
de-sac . The cystic structure
represents the uterus filled with
blood (hematometra), and the
band-like structure represents the
atretic cervix in a patient with
isolated cervical aplasia.
(Left) Sagittal T2WI MR in a

17-year-old girl who presented
with primary amenorrhea and
was found to have a small
vaginal dimple shows a small
triangular structure at the
expected location of the uterus.
No discernible cervix is seen. The
vagina is replaced by a fine cord-
like structure . (Right) Axial
T2WI MR in the same patient
shows normal ovaries and
bilateral symmetrical uterine
buds .
(Left) Axial T2WI MR in the same

patient shows the triangular
fibrotic structure at the
location of the uterus and
bilateral fibrotic bands
connecting to the uterine buds.
(Right) Axial T2WI MR in the
same patient shows a cord-
like fibrous structure at the
expected location of the lower
vagina. Although absence of
the upper 2/3 of the vagina is
seen in almost all cases of MRKH
syndrome, the absence of the
lower 1/3, as in this case, is very
uncommon.
2
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Obgyne Books Full

with primary amenorrhea
and normal external genitalia
shows a small soft tissue
structure at the expected
location of the uterus. No
discernible cervix is seen.
The lower 1/3 of the vagina
is present . A Skene gland
cyst is incidentally noted.
same patient shows absent
vagina .
(Left) Axial T2WI MR in the

same patient shows bilateral
fibrotic bands connecting
to the uterine buds. Both
ovaries are normal. Small
amount of free pelvic fluid
is present, likely from
rupture of an ovarian cyst.
(Right) Axial T1WI C+ FS MR
in the same patient shows
enhancement of the right
fibrotic band . These
bands can enhance to varying
degrees. Both ovaries
appear normal.
(Left) Coronal T2WI MR

the bilateral uterine buds
without differentiation
into uterine zonal anatomy.
The right ovary is seen
and appears normal. (Right)
Coronal T1WI C+ FS MR in
the same patient shows the
bilateral enhancing uterine
buds and a normal-
appearing right ovary .
2
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Obgyne Books Full
Uterus
with primary amenorrhea and
cyclic pelvic pain shows a small
soft tissue structure at the
expected location of the uterus.
No discernible cervix is seen. The
lower 1/3 of the vagina, filled
with ultrasound gel, is present
. (Right) Axial T2WI MR in the
same patient shows a right pelvic
mass separate from the ovary
.
(Left) Sagittal T2WI MR in

right pelvic mass separate
from the ovary . The mass,
representing a rudimentary
uterus, has a target appearance
with differentiation into
endometrium, junctional zone,
and myometrium. (Right)
Axial T1WI C+ FS MR in the
same patient shows diffuse
homogeneous enhancement of
the rudimentary uterine mass .
The rudimentary uterine masses
can occur anywhere within the
pelvis and can even occur in the
inguinal canals.
(Left) Axial T2WI MR in a 19-

year-old girl who presented with
primary amenorrhea shows
bilateral uterine buds with no
cavity, no endometrium, and no
myometrial zonal differentiation.
(Right) Coronal T2WI MR in
the same patient shows bilateral
uterine buds and a normal-
appearing left ovary .
2
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Obgyne Books Full
Uterus UNICORNUATE UTERUS
Key Facts
Terminology • Pedunculated leiomyoma
• Class II müllerian duct anomaly • Hemorrhagic degeneration of leiomyoma
Imaging
• Cystic adenomyosis
• Small, banana-shaped uterus, deviated to 1 side of Clinical Issues
pelvis with single cornua • Most common signs/symptoms
• 4 potential subtypes o Unicornuate uterus ± communicating rudimentary
o No rudimentary horn (35%) horn are usually incidental findings in adults during
o Rudimentary horn with no uterine cavity (no investigation for infertility or other pelvic pathology
endometrial segment) (33%) • Treatment
o Rudimentary horn with noncommunicating cavity o Laparoscopic salpingectomy for communicating
(22%) cavitary uterine horn to reduce risk of pregnancy in
o Rudimentary horn with communicating cavity to rudimentary horn
normal side (10%) o Excision of rudimentary horn in
noncommunicating type (usually via laparoscopic
Top Differential Diagnoses approach) for symptomatic relief of hematometra
• Bicornuate uterus and prevention of endometriosis
• Uterus didelphys
Graphic illustrates the different subtypes of unicornuate uterus (Class II müllerian duct anomaly [MDA]): (1) No rudimentary horn (35%), (2)
rudimentary horn with no uterine cavity (no endometrial segment) (33%), (3) rudimentary horn with a noncommunicating cavity (22%), and
(4) rudimentary horn with a communicating cavity to the normal side (10%).
2
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UNICORNUATE UTERUS
Uterus
TERMINOLOGY ▪ If endometrial tissue is present
– There may be preserved zonal anatomy
Definitions – Rudimentary horn may become distended with
• Class II müllerian duct anomaly (MDA) based blood products if there is no communication
on Buttram & Gibbons and American Society for with fully developed uterine horn
Reproductive Medicine revision – Noncommunicating rudimentary horn with
endometrium may manifest as large uterine mass
IMAGING • T1WI C+ FS
o Dominant and rudimentary horns show normal
General Features myometrial enhancement
• Best diagnostic clue Ultrasonographic Findings
o Small, banana-shaped uterus, deviated to 1 side of
• Often difficult to detect, especially if not suspected
•
pelvis with single cornua
Size
• Small, oblong, off-midline structure
o Improve detection rate by systematically identifying
o Unicornuate uteri are generally smaller than normal
both cornua
•
nulliparous uteri
Morphology
• Rudimentary horn is often hard to identify and may be
misdiagnosed as pelvic mass or cervix
o Small, elliptical uterus, shifted off midline, ± small
residual rudimentary horn Imaging Recommendations
▪ 4 potential subtypes • Best imaging tool
– No rudimentary horn (35%) o MR allows accurate classification of unicornuate
– Rudimentary horn with no uterine cavity (no uterus
endometrial segment) (33%)
– Rudimentary horn with noncommunicating
cavity (22%)
– Rudimentary horn with communicating cavity Bicornuate Uterus
to normal side (10%)
o Fallopian tube of nondominant horn
• Symmetric duplication of uterine horns with
communicating endometrial cavities
▪ Absent in unicornuate uterus without rudimentary
horn and in presence of small atretic residual horn Uterus Didelphys
▪ Both fallopian tubes are present with other types • Complete, symmetric duplication of uterine corpus
o Both ovaries are present and normal and cervix
Hysterosalpingography (HSG) Pedunculated Leiomyoma

• Off-midline fusiform small uterine cavity, tapers at • Uterus of normal volume with 2 cornua
apex • Leiomyomas are typically round in configuration
• Contrast opacification of solitary fallopian tube
Hemorrhagic Degeneration of Leiomyoma
• Opacification of small, communicating, rudimentary
• Mimics obstructed cavitary rudimentary horn
• Blood products appear bright on T1WI FS MR
horn may be seen if present
o HSG cannot be used to exclude presence of
noncommunicating rudimentary horn Cystic Adenomyosis
CT Findings • Mimics obstructed cavitary rudimentary horn
• CT not indicated in characterizing MDAs • Uterus of normal volume with 2 cornua
MR Findings
• Well-circumscribed, thick-walled, complex cystic mass
of myometrial origin
• T1WI • Contains blood products, which appear bright on
o Obstructed segment is of high signal intensity T1WI FS MR
o Hematosalpinx and endometriosis are also of high
• Cyst wall of lower signal on T2WI MR than normal
signal intensity myometrium
• T2WI
o Uterus curved, elongated with tapering fundal
segment off midline: "Banana" configuration
PATHOLOGY
o Dominant horn: Uterine volume reduced General Features
▪ Single cornua
▪ Endometrium uniformly narrowed or bullet-
• Etiology
o Normal development of 1 müllerian duct and near-
shaped tapering at cornua complete to complete arrested development of
▪ Normal endometrial to myometrial width and
contralateral duct
ratio
▪ Normal myometrial zonal anatomy
• Genetics
o Majority of cases are sporadic or multifactorial in
o Rudimentary horn
nature
▪ Variable depending on subtype
▪ No endometrium present • Associated abnormalities
o Highest association with renal anomalies of all MDAs
– Zonal anatomy is absent and entire horn may
demonstrate diffuse low signal intensity (40%) 2
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Obgyne Books Full
▪ Always involves kidney ipsilateral to absent or Image Interpretation Pearls

rudimentary horn
▪ Includes ectopic kidney, renal agenesis, cystic
• "Banana" configuration of unicornuate uterus on long-
axis T2WI MR
dysplasia, and duplicated collecting system • Improve detection rate by systematically identifying
Staging, Grading, & Classification both cornua in all patients
• Class IId: Unicornuate uterus, no rudimentary horn
• Unicornuate uterus with rudimentary horn SELECTED REFERENCES
o Class IIc: Noncavitary 1. Devine K et al: Is magnetic resonance imaging sufficient
o Class IIb: Cavitary, noncommunicating to diagnose rudimentary uterine horn? A case report
o Class IIa: Cavitary, communicating and review of the literature. J Minim Invasive Gynecol.
20(4):533-6, 2013
2. Trad M et al: Mullerian duct anomalies and a case study of
CLINICAL ISSUES unicornuate uterus. Radiol Technol. 84(6):571-6, 2013
3. Allen JW et al: Incidence of ovarian maldescent in women
Presentation with mullerian duct anomalies: evaluation by MRI. AJR Am J
• Most common signs/symptoms Roentgenol. 198(4):W381-5, 2012
o Unicornuate uterus ± communicating rudimentary 4. Khati NJ et al: The unicornuate uterus and its variants:
horn are usually incidental findings in adult during clinical presentation, imaging findings, and associated
investigation for infertility or other pelvic pathology complications. J Ultrasound Med. 31(2):319-31, 2012
o Present at puberty with cyclical pelvic pain in cases 5. Bermejo C et al: Three-dimensional ultrasound in the
diagnosis of Müllerian duct anomalies and concordance
of cavitary, noncommunicating uterine horn with with magnetic resonance imaging. Ultrasound Obstet
partially obstructed or aplastic fallopian tube Gynecol. 35(5):593-601, 2010
• Pregnancy in noncommunicating rudimentary horn 6. Junqueira BL et al: Müllerian duct anomalies and mimics
occurs through transperitoneal migration of sperm or in children and adolescents: correlative intraoperative
fertilized ovum assessment with clinical imaging. Radiographics.
o Associated with high rate of spontaneous abortion, 29(4):1085-103, 2009
preterm labor, intrauterine growth retardation, 7. Steinkeler JA et al: Female infertility: a systematic approach
intraperitoneal hemorrhage, and uterine rupture to radiologic imaging and diagnosis. Radiographics.
• Increased incidence of endometriosis in patients with

8.
29(5):1353-70, 2009
Rackow BW et al: Reproductive performance of women
obstructed horn possibly due to retrograde expulsion of with müllerian anomalies. Curr Opin Obstet Gynecol.
menstrual products 19(3):229-37, 2007
9. Troiano RN et al: Mullerian duct anomalies: imaging and
Demographics
• Epidemiology
clinical issues. Radiology. 233(1):19-34, 2004
10. Chakravarti S et al: Rudimentary uterine horn: management
o Accounts for 20% of MDAs of a diagnostic enigma. Acta Obstet Gynecol Scand.
82(12):1153-4, 2003
Natural History & Prognosis 11.
• Obstetric complications among highest of all MDAs
Marten K et al: MRI in the evaluation of müllerian duct
anomalies. Clin Imaging. 27(5):346-50, 2003
o Spontaneous abortion rate: 50% 12. Scarsbrook AF et al: MRI appearances of müllerian duct
o Preterm birth rate: 15% abnormalities. Clin Radiol. 58(10):747-54, 2003
o Fetal survival rate: 40% 13. Troiano RN: Magnetic resonance imaging of mullerian
duct anomalies of the uterus. Top Magn Reson Imaging.
Treatment 14(4):269-79, 2003
• Unicornuate without rudimentary horn 14. Brody JM et al: Unicornuate uterus: imaging appearance,
o Expectant associated anomalies, and clinical implications. AJR Am J
• Unicornuate with noncavitary rudimentary horn

Roentgenol. 171(5):1341-7, 1998
o Expectant
• Unicornuate with cavitary rudimentary uterine horn
o Communicating type
▪ Laparoscopic salpingectomy to reduce risk of
pregnancy in rudimentary horn
o Noncommunicating type
▪ Excision of rudimentary horn (usually via
laparoscopic approach) for symptomatic relief of
hematometra and prevention of endometriosis
Consider
• Possibility of unicornuate uterus
o In female patient being investigated for infertility
o In a postpubertal patient presenting with cyclical
pelvic pain
2
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Obgyne Books Full
UNICORNUATE UTERUS
Uterus
year-old patient who recently
had a C-section and was
suspected to have a unicornuate
uterus shows a single banana-
shaped right uterine horn . No
left uterine horn was identified.
(Right) Axial T2WI MR in a 22-
year-old woman who was noted
to have an unusual configuration
of the uterus on pelvic US
shows a right uterine horn
containing an endometrial cavity
and a small rudimentary left
horn that does not contain
endometrium.
(Left) Coronal T2WI MR in

an 18-year-old woman who
presented with pelvic pain shows
a normal-appearing left uterine
horn and a right side pelvic
structure with a central
area of high T2 signal intensity.
same patient shows a normal
left uterine horn . The right
pelvic structure appears to
be attached to the left uterine
horn by a narrow band . This
represents a unicornuate uterus
with rudimentary horn with a
noncommunicating cavity.

high signal intensity within the
noncommunicating horn .
shows high signal intensity
within the noncommunicating
rudimentary horn consistent
with blood. The presence of
endometrium in a rudimentary
horn is an important finding and
should be reported. This can
manifest clinically with pelvic
pain caused by endometriosis
due to retrograde flow of menses
through the obstructed horn or
due to an obstructed, distended
horn.
2
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Obgyne Books Full
(Left) Axial T2WI MR shows a

normal right uterine horn
and a blood-filled rudimentary
horn . This represents
a unicornuate uterus with
a rudimentary horn with a
noncommunicating cavity.
(Right) Axial T1WI MR in
the same patient shows
high signal intensity blood
within the noncommunicating
rudimentary horn and
within the proximal fallopian
tube due to retrograde
blood that resulted from the
absence of communication
between the rudimentary horn
and the normal uterine horn.
(Left) Axial CECT in a 35-

year-old woman shows an
incidental banana-shaped
right uterine horn . No
rudimentary left horn is
seen. (Right) Coronal CECT
an ectopic, high-positioned
left ovary containing an
ovarian cyst.

incidental banana-shaped left
uterine horn and a small
rudimentary right horn .
(Right) Coronal CECT in the
same patient shows a well-
developed left uterine horn
containing central low density
endometrium and a smaller
rudimentary right horn
without visible endometrium.
2
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Obgyne Books Full
UNICORNUATE UTERUS
Uterus
(Left) Frontal
hysterosalpingography (HSG)
shows a banana-shaped left
uterine horn with contrast
spillage only from the left side
. (Right) Axial T2WI MR
in the same patient shows a
single uterine horn with
preserved zonal anatomy. A
slightly thickened fallopian tube
is seen arising at the cornu.

year-old pregnant woman shows
a fetus and an anterior
placenta . Note the absence
of myometrium between the
placenta and the abdominal
wall. (Right) Sagittal oblique
shows a fetus and an anterior
placenta . Note the absence
of myometrium around the fetal
membranes. This is a case of an
abdominal ectopic pregnancy
due to rupture of a cavitary
rudimentary horn in a patient
with unicornuate uterus.The
empty uterus is present inferior
to the abdominal pregnancy .

patient performed 3 months after
cesarean section and treatment
with methotrexate shows a highly
vascular mass representing
the retained placenta. The uterus
is located behind the mass.
patient 2 years after delivery
shows a peripherally calcified
mass attached to the uterus
with a soft tissue stalk .
2
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Uterus UTERUS DIDELPHYS
Key Facts
Terminology Pathology
• Class III müllerian duct anomaly • Complete failure of müllerian duct fusion
Imaging • Herlyn-Werner-Wunderlich syndrome
o Triad of uterus didelphys, obstructed hemivagina,
• Fundal cleft > 1 cm and ipsilateral renal agenesis
• Complete duplication of uterine horns and cervices
• No communication between duplicated endometrial Clinical Issues
or endocervical cavities • Nonobstructive uterus didelphys
• Duplicated upper vaginas in 75% of cases o Usually asymptomatic
• High signal intensity hematometrocolpos on T1WI in • Uterus didelphys with obstructed hemivagina
presence of transverse vaginal septum o Pelvic mass and dysmenorrhea
Top Differential Diagnoses • 2nd highest probability of successful pregnancy after

arcuate uterus
• Bicornuate bicollis uterus • Treatment
• Unicornuate uterus o Expectant
• Complex duplication anomalies o Metroplasty leaving duplicated cervix intact in
selected patients with recurrent abortions and
premature deliveries
(Left) Graphic of uterus

didelphys shows complete
duplication of uterine
horns and cervices, no
communication between
duplicated endometrial or
endocervical cavities, and
duplicated upper vaginas
(seen in 75% of cases). (Right)
Frontal hysterosalpingography
(HSG) after contrast injection
into both cervices using
2 catheters shows 2
completely separate uterine
horns , each with a separate
fallopian tube .
(Left) Axial 3D ultrasound

shows 2 widely divergent
uterine horns , each
showing echogenic
Coronal T2WI MR shows
widely divergent uterine horns
. Each horn shows a normal
endometrial-myometrial ratio
and normal myometrial zonal
differentiation. Two separate
cervices are also present.
2
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UTERUS DIDELPHYS
Uterus
TERMINOLOGY ▪ Hematosalpinx &/or endometriosis may be present
Definitions Ultrasonographic Findings

• Class III müllerian duct anomaly (MDA) based • Widely divergent, symmetric, endometrial
echocomplexes without communication
on Buttram & Gibbons and American Society for
• 2 distinct cervices need to be documented
• 3D ultrasound may aid in diagnosis, but typically 2
Reproductive Medicine revision
separate uterine horns are well visualized at real-time
IMAGING scanning
General Features Imaging Recommendations
• Best diagnostic clue • Best imaging tool
o Fundal cleft > 1 cm is 100% sensitive and specific in o Pelvic MR modality of choice
differentiation of fusion anomalies (didelphys and o 2D and 3D US can be used as initial imaging modality
bicornuate) from reabsorption anomalies (septate
and arcuate)
o Complete duplication of uterine horns and cervices DIFFERENTIAL DIAGNOSIS
o No communication between duplicated endometrial Bicornuate Unicollis Uterus
or endocervical cavities
o Duplicated upper vaginas in 75% of cases
• Nonfusion confined to uterine corpus
• Size
• Communication between uterine horns at lower
uterine segment must be present
o Uterine volume in each duplicated segment reduced
• Single cervix
• Morphology
o 2 symmetric uterine horns and cervices with minor Bicornuate Bicollis Uterus
degree of fusion at most caudal margin • Separated uterine horns and cervices similar to uterine
o Longitudinal vaginal septum present in 75% of cases didelphys
▪ Occasionally complicated by transverse vaginal • Less divergent uterine horns
septum causing obstruction • Some degree of fusion of myometrium of lower uterine
segment
Hysterosalpingography (HSG)
• 2 separate opacified endocervical canals opening into • Vaginal obstruction is rare
separate, symmetric fusiform endometrial cavities Unicornuate Uterus
• Each cavity ends in solitary fallopian tube • Asymmetric horns with smaller rudimentary horn
• No communication between opacified endocervical • Solitary cervix
and endometrial cavities
• Pitfall: Only 1 cervical os may be cannulated; Complex Duplication Anomalies
endometrial configuration then mimics unicornuate • Comprise features of > 1 class of MDAs
uterus • Most common scenario: Degree of nonfusion is less
than didelphys and greater than bicornuate uterus
CT Findings o Variable fundal duplication of uterine horns with
• CT has no role in characterization of uterus didelphys midline, lower uterine septum
o Solitary or duplicated cervix
MR Findings
• T1WI
o High signal intensity hematometrocolpos in PATHOLOGY
presence of transverse vaginal septum
▪ Associated complications: Hematosalpinx, General Features
endometriosis • Etiology
• T2WI o Results from complete failure of müllerian duct
o 2 separate uteri and cervices fusion
o Uterine volume of each horn reduced o Each duct develops fully with duplication of uterine
▪ Normal uterine/cervical zonal anatomy horns, cervix, and proximal vagina (in 3/4 of
o Cornual segments of horns widely divergent; cervices patients)
usually in close approximation • Associated abnormalities
o Longitudinal vaginal septum: Longitudinal low o Duplicated (proximal) vagina may be associated
signal intensity band extending through vagina, with transverse hemivaginal septum, resulting in
which may be complete or incomplete ipsilateral obstruction and hematometrocolpos
o Obstructing unilateral transverse vaginal septum o Renal anomalies: Agenesis, duplex, or pelvic kidney
▪ Transverse low signal intensity band anywhere o Herlyn-Werner-Wunderlich syndrome
along vagina, usually at junction of upper and ▪ Triad of uterus didelphys, obstructed hemivagina,
middle 1/3 and ipsilateral renal agenesis
▪ Hematometrocolpos with marked dilatation of o Increased incidence of endometriosis in obstructed
obstructed vaginal segment and lesser dilatation of type due to retrograde menstrual flow
uterine segment
▪ Variable signal intensity of hematometrocolpos
depending on stage of hemorrhage 2
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CLINICAL ISSUES Image Interpretation Pearls

Presentation
• 2 separate uteri and cervices identified on T2WI
• Most common signs/symptoms SELECTED REFERENCES
o Nonobstructive uterus didelphys
▪ Usually asymptomatic 1. Bajaj SK et al: OHVIRA: Uterus didelphys, blind hemivagina
▪ Diagnosis made during investigation of recurrent and ipsilateral renal agenesis: Advantage MRI. J Hum Reprod
spontaneous abortions and premature delivery Sci. 5(1):67-70, 2012
o Uterus didelphys with obstructed hemivagina 2. Behr SC et al: Imaging of müllerian duct anomalies.
▪ Frequently symptomatic at menarche with pelvic Radiographics. 32(6):E233-50, 2012
3. Del Vescovo R et al: Herlyn-Werner-Wunderlich syndrome:
mass (hematometrocolpos) and dysmenorrhea MRI findings, radiological guide (two cases and literature
▪ Hematometrocolpos may cause acute urinary review), and differential diagnosis. BMC Med Imaging. 12:4,
retention or other pressure effects 2012
▪ Superinfection presents with fever, peritonitis, and 4. Schutt AK et al: Perioperative evaluation in Herlyn-
vaginal discharge Werner-Wunderlich syndrome. Obstet Gynecol.
▪ Endometriosis and pelvic adhesions due to 2012 Oct;120(4):948-51. Erratum in: Obstet Gynecol.
retrograde menstrual flow from obstructed side 120(6):1483, 2012
• Other signs/symptoms 5. Takahata A et al: Plicae palmatae of the cervical canals
in uterus didelphys: MR imaging. Abdom Imaging.
o Rarely acute rupture of hematosalpinx, presenting 37(5):912-3, 2012
with peritonitis 6. Talebian Yazdi A et al: Uterus didelphys with obstructed
hemivagina and renal agenesis: MRI findings. JBR-BTR.
Demographics
• Age
94(1):16-8, 2011
7. Junqueira BL et al: Müllerian duct anomalies and mimics
o Developmental abnormality which usually presents in children and adolescents: correlative intraoperative
at menarche or later assessment with clinical imaging. Radiographics.
• Ethnicity 29(4):1085-103, 2009
o No ethnic predilection 8. Kimble RM et al: The obstructed hemivagina, ipsilateral
• Epidemiology
renal anomaly, uterus didelphys triad. Aust N Z J Obstet
Gynaecol. 49(5):554-7, 2009
o Accounts for 5% of MDAs 9. Bhattacharya K et al: Uterus didelphys with fibroid uterus
and ovarian cyst--rare Muellerian malformation. J Indian
• Compared to other uterine anomalies
Med Assoc. 104(6):336-7, 2006
10. Prada Arias M et al: Uterus didelphys with obstructed
o 2nd highest probability of successful pregnancy after hemivagina and multicystic dysplastic kidney. Eur J Pediatr
arcuate uterus Surg. 15(6):441-5, 2005
o Reproductive outcomes slightly better than 11. Montevecchi L et al: Resectoscopic treatment of complete
unicornuate uterus longitudinal vaginal septum. Int J Gynaecol Obstet.
▪ Possibly secondary to better uterine perfusion 84(1):65-70, 2004
•
12. Troiano RN et al: Mullerian duct anomalies: imaging and
Simultaneous pregnancy in both uteri reported clinical issues. Radiology. 233(1):19-34, 2004
• Breech presentation with pregnancy is common (45%) 13. Dalkalitsis N et al: Unicornuate uterus and uterus didelphys
• Spontaneous abortion rate: 45% (range: 32-52%) indications and techniques for surgical reconstruction: a
• Premature birth rate: 40% (range: 20-45%) review. Clin Exp Obstet Gynecol. 30(2-3):137-43, 2003
•
14. Hinckley MD et al: Management of uterus didelphys,
Fetal survival rate: 55% (range: 41-64%) obstructed hemivagina and ipsilateral renal agenesis. A case
report. J Reprod Med. 48(8):649-51, 2003
Treatment
• Expectant
15. Takagi H et al: Magnetic resonance imaging in the
evaluating of double uterus and associated urinary tract
• Metroplasty leaves duplicated cervix intact in selected anomalies: a report of five cases. J Obstet Gynaecol.
patients with recurrent spontaneous abortions and 23(5):525-7, 2003
premature deliveries 16. Woodward PJ et al: MR imaging in the evaluation of female
o Traditionally performed abdominally via infertility. Radiographics. 13(2):293-310, 1993
Pfannenstiel approach (e.g., Strassman metroplasty)
o Currently performed by combined hysteroscopic and
laparoscopic approach
o Benefits of metroplasty are unclear
• Hysteroscopic resection of vaginal septum in patients
with obstructing vaginal septum
Consider
• Uterus didelphys with obstruction in patient
presenting at menarche with cyclical dysmenorrhea
and pelvic mass
2
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UTERUS DIDELPHYS
Uterus
(Left) Frontal HSG after
cannulation of the right cervix
shows a small banana-shaped
uterine horn resembling the
appearance of a unicornuate
uterus. (Right) Frontal HSG in
the same patient after a contrast
injection into both cervices
shows 2 completely separate
uterine horns , each with a
separate cervix and fallopian
tube . Failure to recognize
the presence of 2 cervices can
lead to an erroneous diagnosis of
unicornuate uterus.

year-old woman shows 2 widely
separated uterine horns .
Myometrial zonal anatomy is
preserved in both horns and
both horns show focal areas of
thickening of the junctional zone
due to focal adenomyosis.
same patient shows 2 separate
uterine horns and cervices
.
(Left) Axial transabdominal

ultrasound (composite image)
in a 24-year-old woman who
presented with pelvic pain shows
2 widely divergent uterine horns
each containing echogenic
endometrium . The lower part
of the image shows 2 separate
cervices . (Right) Axial
transabdominal pelvic ultrasound
shows 2 widely separated uterine
horns with a gestational sac
containing an embryo within
the right uterine horn.
2
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Obgyne Books Full

year-old girl who presented
with severe pelvic pain shows
a uterus didelphys with 2
uterine horns . A fundal
cleft of 15 mm is present .
The left uterine horn and left
hemivagina are markedly
distended. (Right) Axial T2WI
MR in the same patient shows
a distended left hemivagina
and a decompressed right
hemivagina .

same patient shows high
T1 signal intensity of the
contents of the distended left
uterine horn . (Right) Axial
shows marked distension
of the left hemivagina
with high signal intensity
contents. The high T1 signal
intensity within the left uterine
horn and left hemivagina is
due to blood accumulation
(hematometrocolpos).
(Left) Coronal T2WI MR in the

same patient shows separation
of the 2 uterine horns with
normal zonal anatomy of the
right horn and distended
left horn . (Right) Sagittal
shows distension of both the
uterus and left hemivagina
due to a lower vaginal
septum . The left kidney
was absent. This is a case of
Herlyn-Werner-Wunderlich
syndrome characterized by
a triad of uterine didelphys,
obstructed hemivagina, and
ipsilateral renal agenesis.
2
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UTERUS DIDELPHYS
Uterus
year-old woman who presented
with repeated pregnancy loss
shows widely separated uterine
horns . The 2 horns are
symmetrical and show a normal
endometrial:myometrial ratio
anatomy. (Right) Axial T2WI
2 separate cervices , each
showing a normal complete ring
of low signal intensity fibrous
stroma.

with pelvic pain shows 2 widely
divergent uterine horns and
2 cervices . Focal thickening
of the junctional zone within
the right uterine horn due
to adenomyosis is present.
widely divergent uterine horns
, each showing myometrial
zonal differentiation. Focal
adenomyosis of the right horn
is also seen.
(Left) Axial CECT in a 30-year-

old woman who presented with
intestinal obstruction shows
2 separate uterine horns .
same patient shows widely
separated uterine horns with
2 separate cervices . Although
CT is not adequate for evaluation
of uterine anomalies, it is
occasionally possible to identify
and correctly characterize these
anomalies with proper reformats.
2
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Uterus BICORNUATE
Key Facts
• Class IV müllerian duct anomaly (MDA) • Septate uterus
• Incomplete fusion of fundal myometrium with 2 • Uterus didelphys
symmetric, communicating uterine horns • Unicornuate with rudimentary horn
Imaging • Arcuate uterus
• Fundal cleft > 1 cm separating divergent, symmetric Pathology
uterine horns
• Uterine horns symmetric in size and appearance • Highest association with cervical incompetence (38%)
among MDAs
o Bicornuate unicollis: Solitary cervix
o Bicornuate bicollis: Duplicated cervix Clinical Issues
• Hysterosalpingography (HSG) • Adverse reproductive outcomes: Increased rates of
o Fusiform symmetric uterine cavities, tapering at spontaneous abortions and premature deliveries
cornua, with each horn ending in 1 fallopian tube • Minimal if any impact on fertility in absence of
o Significant overlap of findings with septate uterus extrauterine causes
• MR • Hysteroscopic partial restoration of uterine cavity in
o Modality of choice partial bicornuate uterus
(Left) Graphic of a bicornuate

uterus shows incomplete
fusion of fundal myometrium
with cleft separating divergent,
symmetric horns. With partial
bicornuate uterus, there is
communication between the 2
uterine cavities, whereas with
complete bicornuate uterus,
there is a septum that extends
to the level of the cervix.
(Right) Frontal HSG shows 2
symmetric divergent uterine
horns with a divergence
angle of 100° and intercornual
distance of 5 cm.
(Left) Axial T2WI MR shows 2

symmetrical uterine horns
separated by a deep cleft (> 1
cm in depth) . The septum
is complete, extending
to the level of the internal
cervical os. (Right) Axial T2WI
MR (composite image of
2 different levels) shows 2
symmetric divergent horns
with communication at
the level of the lower uterine
segment .
2
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BICORNUATE
Uterus
o SI of tissue separating horns identical to myometrium
TERMINOLOGY
on all sequences
Definitions ▪ Low SI of inferior portion of septum if fibrous
• Class IV müllerian duct anomaly (MDA) o Accuracy of MR: 100%
o Based on Buttram & Gibbons/American Fertility
Society (AFS) classification system
o Complete (IVa): Fundal cleft extending to internal • Grayscale ultrasound
o True orthogonal view along long axis is essential for
cervical os
o Partial (IVb): Fundal cleft variable in length, ending diagnosis
▪ Large fundal cleft > 1 cm
proximal to internal os
▪ Fundal indentation of external contour below or ≤
• Incomplete fusion of fundal myometrium with 2
5 mm above interostial line
symmetric, communicating uterine horns o Widely divergent, symmetric, normal-appearing
echogenic endometrial complexes
IMAGING o Endometrial complexes convergent at caudal extent
o Echogenicity of tissue separating horns identical to
General Features myometrium
• Best diagnostic clue o Pitfall: Extreme anteflexion or retroflexion and
o Fundal cleft > 1 cm separating divergent, symmetric coexisting fundal leiomyomas causing convexity of
uterine horns fundal contour
o Uterine horns symmetric in size and appearance o Accuracy of transvaginal ultrasound (TVS): 90-92%
o Communication between uterine horns must be
present to make diagnosis Imaging Recommendations
• Morphology • Best imaging tool
o Bicornuate unicollis: Solitary cervix o 2D and 3D ultrasound can be used as initial imaging
o Bicornuate bicollis: Duplicated cervix modality
▪ Communication at endometrial or endocervical o MR is modality of choice in patients with adverse
level; uncommonly, may only be fenestrations reproductive outcomes: 100% accuracy for
differentiating septate from bicornuate uterus and
Radiographic Findings bicornuate from complex duplication anomaly
• Hysterosalpingography (HSG) ▪ Allows for optimal assessment of coexisting
o Fusiform symmetric uterine cavities, tapering at uterine pathologies affecting fertility (leiomyomas,
cornua, with each horn ending in 1 fallopian tube adenomyosis, endometriosis)
o Significant overlap of findings with septate uterus
▪ Intercornual distance > 4 cm favors bicornuate
uterus
▪ High divergence angle (> 105° ) between opacified Septate Uterus
endometrial cavities suggestive of bicornuate
• Fused external fundal myometrium
uterus
▪ Acute angle (< 75° ) between uterine horns • External uterine contour is convex, flat, or concave <
1.0 cm
suggestive of septate uterus
o Accuracy of HSG for differentiating septate from Uterus Didelphys
bicornuate uterus: 55% • Near-complete duplication of uterus
▪ Accuracy improved if contrast spilled from tubes • Normal zonal anatomy of corpus and cervix within
outlines uterine fundal contour each hemiuterus
▪ Accuracy increased to 90% if combined with • No communication between endometrial cavities
sonohysterography
o Pitfall: Secondary distortion and widening of Complex Duplication Anomaly
divergence angles with septal adenomyosis or • Comprise features of > 1 class of MDAs
insinuated leiomyoma • Most common scenario: Degree of nonfusion <
didelphys > bicornuate uterus
MR Findings o May result in a "bicornuate configuration" of uterine
• T1WI horns without a communicating segment
o Inferior portion of septum low signal intensity (SI) if
fibrous Unicornuate With Rudimentary Horn
• T2WI • Asymmetric uterine horns
o Uterine horns separated by intervening cleft in • Diminutive rudimentary horn with small, contracted
external fundal myometrium > 1.0 cm endometrial segment
▪ Measured from apex of fundal cleft to line Arcuate Uterus
connecting serosal contour of uterine horns
o Symmetric uterine horns, each with normal • Fused external fundal myometrium
circumferential zonal anatomy • Mild indentation of myometrium on endometrial
cavity
▪ Communication between endometrial or
endocervical canal essential for diagnosis
2
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Uterus BICORNUATE
o Wedge resection of medial aspect of each uterine

PATHOLOGY
horn with subsequent unification of cavities
General Features o No increased risk of complications in subsequent
• Etiology pregnancies
o Abnormality of lateral fusion of normally developed
müllerian (paramesonephric) ducts DIAGNOSTIC CHECKLIST
▪ Incomplete fusion of cephalad extent of
uterovaginal horns Consider
• Associated abnormalities • Distinction from septate uterus is critical due to
o Highest association with cervical incompetence different surgical treatments
(38%) among MDAs
o Associated anomalies due to defects of vertical Image Interpretation Pearls
fusion, mesonephric induction, and uterovaginal • Evaluation of external uterine contour is crucial for
differentiating septate from bicornuate uterus
septum resorption
▪ Renal anomalies, most commonly agenesis • Mild concavity (≤ 1 cm) of external uterine contour
should not be construed as “partial” bicornuate
▪ Associated longitudinal vaginal septa in 25%
configuration
▪ Occasional association with transverse vaginal
septa
Staging, Grading, & Classification SELECTED REFERENCES
• Complete vs. partial 1. Ludwin A et al: Two- and three-dimensional
• Unicollis vs. bicollis ultrasonography and sonohysterography versus
hysteroscopy with laparoscopy in the differential diagnosis
Gross Pathologic & Surgical Features of septate, bicornuate, and arcuate uteri. J Minim Invasive
• 2 uterine horns, each with uterine cavity, 2.

Gynecol. 20(1):90-9, 2013
Behr SC et al: Imaging of müllerian duct anomalies.
endometrium, myometrium, and covering serosa Radiographics. 32(6):E233-50, 2012
Microscopic Features 3. Ludwin A et al: Diagnostic accuracy of sonohysterography,
• Septum composed of either myometrium or hysterosalpingography and diagnostic hysteroscopy in

diagnosis of arcuate, septate and bicornuate uterus. J Obstet
myometrium and fibrous tissue combined Gynaecol Res. 37(3):178-86, 2011
o Septum covered by normal functional endometrium 4. Marcal L et al: Mullerian duct anomalies: MR imaging.
Abdom Imaging. 36(6):756-64, 2011
5. Carrascosa PM et al: Virtual hysterosalpingography: a new
CLINICAL ISSUES multidetector CT technique for evaluating the female
reproductive system. Radiographics. 30(3):643-61, 2010
Presentation
6. Junqueira BL et al: Müllerian duct anomalies and mimics
in children and adolescents: correlative intraoperative
o Adverse reproductive outcomes: Increased rates of assessment with clinical imaging. Radiographics.
spontaneous abortions and premature deliveries 29(4):1085-103, 2009
▪ Greater with complete than partial configuration 7. Steinkeler JA et al: Female infertility: a systematic approach
▪ Spontaneous abortion rate: 30% to radiologic imaging and diagnosis. Radiographics.
▪ Preterm birth rate: 20% 29(5):1353-70, 2009
▪ Fetal survival rate: 60% 8. Papp Z et al: Reproductive performance after
transabdominal metroplasty: a review of 157 consecutive
Demographics cases. J Reprod Med. 51(7):544-52, 2006
• Epidemiology 9. Troiano RN et al: Mullerian duct anomalies: imaging and
clinical issues. Radiology. 233(1):19-34, 2004
o Accounts for 10% of MDAs
10. Troiano RN: Magnetic resonance imaging of mullerian
Natural History & Prognosis duct anomalies of the uterus. Top Magn Reson Imaging.
• Asymptomatic during childhood or at puberty if 11.

14(4):269-79, 2003
Grimbizis GF et al: Clinical implications of uterine
unaccompanied by obstruction malformations and hysteroscopic treatment results. Hum
• Minimal if any impact on fertility in absence of Reprod Update. 7(2):161-74, 2001
extrauterine causes 12. Ascher SM: MR imaging of the female pelvis: the time has
• Increasing length of subsequent gestations with 13.
come. Radiographics. 18(4):931-45, 1998
Wu MH et al: Detection of congenital mullerian duct
increasing parity
• Significant improvement in reproductive capacity and anomalies using three-dimensional ultrasound. J Clin
Ultrasound. 25(9):487-92, 1997
fetal survival rates after metroplasty
14. Pellerito JS et al: Diagnosis of uterine anomalies: relative
Treatment accuracy of MR imaging, endovaginal sonography, and
• Prophylactic cervical cerclage in selected patients 15.
hysterosalpingography. Radiology. 183(3):795-800, 1992
Carrington BM et al: Mullerian duct anomalies: MR imaging
associated with increased fetal survival rates
• Hysteroscopic partial restoration of uterine cavity in
evaluation. Radiology. 176(3):715-20, 1990
16. Fedele L et al: Magnetic resonance evaluation of double
partial bicornuate uterus uteri. Obstet Gynecol. 74(6):844-7, 1989
• Metroplasty (variation of Strassman procedure) using 17. Reuter KL et al: Septate versus bicornuate uteri: errors in
a hysteroscopic and laparoscopic approach is reserved imaging diagnosis. Radiology. 172(3):749-52, 1989
for patients with recurrent 2nd- and 3rd-trimester
2 pregnancy loss
40
Obgyne Books Full
BICORNUATE
Uterus
2 symmetrical well-developed
uterine horns separated by
a deep fundal cleft (> 1 cm
deep). The septum extends to
the level of the cervix . (Right)
Axial T2WI MR in the same
patient shows 2 symmetrical
well-developed uterine horns
separated by a deep fundal cleft
(> 1 cm deep) . There are 2
separate cervices (bicornuate
bicollis). The degree of fusion is
more than expected for didelphys
uterus.
(Left) Sagittal transabdominal

ultrasound in a 23-year-old
woman during routine obstetric
ultrasound shows a fetal
head and an echogenic
mass separate from the
gravid uterus. (Right) Sagittal
transabdominal ultrasound in
echogenic pelvic mass . This
was thought to represent an
ovarian mass, possibly a mature
cystic teratoma.

same patient following delivery
shows a bicornuate uterus with
2 separate uterine horns
separated by a deep cleft .
The right, previously gravid horn
contains blood products. The
left nongravid horn is empty.
same patient shows the enlarged
postpartum right horn and a
single dilated cervix .
2
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Obgyne Books Full
Uterus SEPTATE UTERUS
Key Facts
Terminology o Muscular component of septum is isointense to
• Class V müllerian duct anomaly myometrium
o Fibrous component of septum is of low signal
• Incomplete resorption of uterovaginal septum intensity relative to myometrium
o Complete: Septum extends to external os
o Partial: Septum ends proximal to external cervical os Top Differential Diagnoses
Imaging • Bicornuate uterus
• Uterine fundal contour is flat, convex, or mildly • Arcuate uterus
concave ≤ 1 cm depth • Didelphys uterus
• Septum arises midline in fundus separating 2 • Unicornuate uterus with rudimentary horn
endometrial cavities
o Superior segment of septum is myometrial Clinical Issues
o Inferior segment of septum is fibrous • Repeated midtrimester pregnancy loss
• Duplication of cervix with complete septa included in • Most common müllerian duct anomaly
classification • Worst obstetric outcome of all müllerian duct
• Hysterosalpingography (HSG) cannot evaluate anomalies
external fundal contour • Often treated with transvaginal hysteroscopic
• T2WI MR resection of septum
(Left) Graphic shows the 2

forms of septate uterus. There
is complete fusion of the
fundal myometrium. In the
complete type, the septum
extends to the external os
and may even extend into the
vagina. On the other hand,
in the partial type, there is
variable length septum ending
proximal to external cervical
os. (Right) Coronal oblique
T2WI MR shows a partial
septate uterus. The septum
does not reach to the external
os. The external contour is flat
. The fibrous lower part of
the septum shows low T2
signal intensity.
(Left) Coronal 3D ultrasound

shows a septate uterus. The
outer fundal contour is slightly
concave with a shallow
cleft < 1 cm . There is
an incomplete septum
extending to the lower uterine
segment. (Right) Frontal HSG
in a patient with septate uterus
shows 2 uterine horns
separated by a thick septum
. Findings that suggest a
septate uterus rather than
bicornuate are an acute angle
(< 75° ) between endometrial
cavities and an intercornual
distance < 4.0 cm.
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SEPTATE UTERUS
Uterus
o Accuracy of HSG for differentiating septate from
TERMINOLOGY
bicornuate uterus is 55%
Definitions • HSG accuracy for diagnosis of septate uterus: 29%
• Class V müllerian duct anomaly based on Buttram MR Findings
• T2WI
& Gibbons classification and American Society for
• Incomplete resorption of uterovaginal septum o Normal external fundal contour
o High T2 signal intensity endometrial cavities
o Complete: Septum extends to external os and may
even extend into vagina separated by septum
o Partial: Variable length septum ending proximal to ▪ Muscular component of septum is isointense to
external cervical os myometrium
▪ Fibrous component of septum is of low signal
• Class U2 of ESHRE/ESGE consensus on classification of
intensity relative to myometrium
female genital tract congenital anomalies
o Incorporates all cases with normal fusion and o Complete duplication of normal cervical zonal
abnormal absorption of midline septum anatomy in complete septa with 2 cervices
o Septate is defined as uterus with normal outline and o Accuracy: 100%; sensitivity: 100%; specificity: 100%
internal indentation at fundal midline exceeding • T1WI C+
50% of uterine wall thickness o May help define uterine fundal contour if difficult to
o Class U2 is further divided into 2 subclasses identify on T2WI because of bowel applied to uterus
according to degree of uterine corpus deformity Ultrasonographic Findings
▪ Class U2a (or partial septate uterus) characterized
by existence of a septum partly dividing uterine
• Grayscale ultrasound
o Echogenic endometrial cavities separated by a
cavity above level of internal cervical os
septum
▪ Class U2b (or complete septate uterus)
▪ Muscular component of septum has echogenicity
characterized by existence of septum fully dividing
similar to myometrium
uterine cavity up to level of internal cervical os ▪ Fibrous component of septum is less echogenic
relative to myometrium
IMAGING o Apex of external fundal contour is > 5 mm above
interostial line (line drawn between uterine ostia)
General Features o Accuracy: 92%; sensitivity: 100%; specificity 80%
• Best diagnostic clue o 3D US to improve visualization of external fundal
o Uterine fundal contour is flat, convex, or mildly contour
concave with ≤ 1 cm depth
o Midline septum with fusion of fundal Imaging Recommendations
myometrium • Best imaging tool
▪ Complete: Septum extends to external cervical os o T2 MR is most accurate imaging modality
▪ Partial: Variable length septum o Role of 3D sonohysterography emerging
o Symmetric small and narrow endometrial cavities
• Size DIFFERENTIAL DIAGNOSIS
o Normal-sized uterus, but each endometrial cavity is
narrower and smaller than normal Bicornuate Uterus
• Morphology • Nonfusion fundal myometrium
o Uterus is normal in size • Intervening cleft > 1.0 cm
o Normal external uterine fundal contour
▪ Convex, flat, or concave with ≤ 1 cm depth Arcuate Uterus
o Septum arises midline in fundus separating 2 • Mild indentation of fundal myometrium on
endometrial cavity
• Defining depth to differentiate arcuate from broad
endometrial cavities
▪ Superior segment of septum is myometrial in
septum not established
• Blunt myometrial-endometrial interface with arcuate
composition
▪ Inferior segment of septum is fibrous
o Endometrial cavities are narrower and smaller uterus rather than more angular interface in septate
o Duplication of cervix with complete septa included uterus
in classification Didelphys Uterus
o Extension of septum to upper 1/3 of vagina in 25%
• Near complete duplication of uterus
Hysterosalpingography (HSG) • Normal zonal anatomy of corpus and cervix within
• Cannot evaluate external fundal contour and therefore each hemiuterus
does not allow reliable differentiation of septate from • No communication between endometrial canals
bicornuate uterus Unicornuate Uterus With Rudimentary Horn
o Findings historically favoring diagnosis of septate
• Asymmetric uterine horns
• Fundal cleft typically > 1 cm
rather than bicornuate uterus are
▪ Intercornual distance < 4.0 cm
▪ Acute angle (< 75° ) between uterine horns
2
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PATHOLOGY DIAGNOSTIC CHECKLIST

General Features Image Interpretation Pearls
• Associated abnormalities • Duplication of endometrial cavity with intervening
o Complete uterine septum can be associated with fibromuscular septum, with fusion of fundal
obstructed hemivagina (due to transverse lower myometrium leading to a flat, convex, or mildly
vaginal septum) and ipsilateral renal agenesis concave fundal contour is diagnostic
o Ovarian maldescent (ovarian pole located above iliac • Distinction from bicornuate uterus critical due to
bifurcation) occurs in ~ 10% of patients with septate different surgical treatments
uterus
Staging, Grading, & Classification SELECTED REFERENCES
• Complete 1. Bermejo C et al: Three-dimensional ultrasound and
• Partial magnetic resonance imaging assessment of cervix and
vagina in women with uterine malformations. Ultrasound
Microscopic Features Obstet Gynecol. 43(3):336-45, 2014
• Deficient septal composition 2. Fedele L et al: Double uterus with obstructed hemivagina
o Increased amount of muscular tissue: Perhaps leading and ipsilateral renal agenesis: pelvic anatomic variants in 87
cases. Hum Reprod. 28(6):1580-3, 2013
to increased contractility
3. Grimbizis GF et al: The ESHRE-ESGE consensus on the
o Decreased connective tissue: May result in poor
classification of female genital tract congenital anomalies.
decidualization Gynecol Surg. 10(3):199-212, 2013
• Septal endometrium is irregular by electron microscopy 4. Allen JW et al: Incidence of ovarian maldescent in women
with mullerian duct anomalies: evaluation by MRI. AJR Am J
Roentgenol. 198(4):W381-5, 2012
CLINICAL ISSUES 5. Behr SC et al: Imaging of müllerian duct anomalies.
Presentation 6. Faivre E et al: Accuracy of three-dimensional
• Most common signs/symptoms ultrasonography in differential diagnosis of septate and
o Recurrent pregnancy loss bicornuate uterus compared with office hysteroscopy and
▪ Particularly midtrimester pregnancy loss pelvic magnetic resonance imaging. J Minim Invasive
▪ Spontaneous abortion rate: 32-94% (65% pooled) Gynecol. 19(1):101-6, 2012
▪ Etiology: Increased contractility, poor 7. Bermejo C et al: Three-dimensional ultrasound in the
diagnosis of Müllerian duct anomalies and concordance
decidualization &/or reduction in endometrial with magnetic resonance imaging. Ultrasound Obstet
capacity Gynecol. 35(5):593-601, 2010
• Other signs/symptoms 8. Ghi T et al: Accuracy of three-dimensional ultrasound in
o Increased incidence of renal anomalies diagnosis and classification of congenital uterine anomalies.
Fertil Steril. 92(2):808-13, 2009
Demographics 9. Mueller GC et al: Müllerian duct anomalies: comparison of
• Epidemiology MRI diagnosis and clinical diagnosis. AJR Am J Roentgenol.
o Most common müllerian duct anomaly 189(6):1294-302, 2007
▪ ~ 55% of cases 10. Takeuchi M et al: Pathologies of the uterine endometrial
cavity: usual and unusual manifestations and pitfalls on
Natural History & Prognosis magnetic resonance imaging. Eur Radiol. 15(11):2244-55,
• Worst obstetric outcome of all müllerian duct 11.
2005
Patton PE et al: The diagnosis and reproductive outcome
anomalies
o Length of septum does not correlate with obstetric after surgical treatment of the complete septate uterus,
duplicated cervix and vaginal septum. Am J Obstet Gynecol.
outcome
•
190(6):1669-75; discussion 1675-8, 2004
Reproductive outcome in women with untreated 12. Marten K et al: MRI in the evaluation of mullerian duct
septate uteri anomalies. Clin Imaging. 27(5):346-50, 2003
o Live birth rate: 5% 13. Letterie GS et al: A comparison of pelvic ultrasound and
• Reproductive outcome after hysteroscopic septal magnetic resonance imaging as diagnostic studies for
mullerian tract abnormalities. Int J Fertil Menopausal Stud.
resection is good
o Successful delivery rate: 85% 40(1):34-8, 1995
o Spontaneous abortion rate: 6% 14. Ozsarlak O et al: Septate uterus: hysterosalpingography
and magnetic resonance imaging findings. Eur J Radiol.
Treatment 21(2):122-5, 1995
• Often treated with transvaginal hysteroscopic resection 15. Woodward PJ et al: Congenital uterine malformations. Curr
Probl Diagn Radiol. 24(5):178-97, 1995
of the septum 16. Woodward PJ et al: MR imaging in the evaluation of female
o Conception is possible 2 months after surgery
infertility. Radiographics. 13(2):293-310, 1993
o Residual septum < 1 cm following resection 17. Markham SM et al: Structural anomalies of the reproductive
considered optimal tract. Curr Opin Obstet Gynecol. 4(6):867-73, 1992
18. Buttram VC Jr et al: Mullerian anomalies: a proposed
classification. (An analysis of 144 cases). Fertil Steril.
32(1):40-6, 1979
2
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SEPTATE UTERUS
Uterus
(Left) Coronal oblique T2WI
MR shows a septate uterus
with 2 horns and a long fibrous
septum extending to the
external os. The external fundal
contour shows mild indentation
through the upper (above)
and lower (below) vagina in
septum extending into the
upper vagina, separating it into
2 compartments , but it does
not extend into the lower vagina,
which is composed of only 1
compartment .
(Left) Axial T2WI MR shows 2

uterine horns in a retroverted
uterus separated by a septum
. Note the convex external
fundal contour . (Right)
Coronal T2WI MR in the
same patient shows a convex
external fundal contour
and a predominantly muscular
uterine septum . There is also
an associated vertical vaginal
septum separating the vagina
into 2 compartments, each filled
with ultrasound gel.
(Left) Frontal
hysterosalpingogram (HSG)
in a 25-year-old woman with
recurrent pregnancy loss shows
2 separate uterine horns .
same patient shows 2 uterine
horns in a retroverted uterus
separated by a septum and
a flat external fundal contour
. This case illustrates the
inaccuracy of HSG in diagnosing
septate uterus because of its
inability to visualize the external
fundal contour.
2
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(Left) Axial T2WI MR in a

29-year-old woman with
septate uterus. The external
fundal contour is almost
flat, and the septum is
entirely fibrous, showing very
low signal intensity. (Right)
Axial T2WI MR in a 30-year-
old woman with history of
recurrent pregnancy losses
shows 2 uterine horns
separated by a septum .
The external fundal contour is
flat . The signal intensity of
the fundal myometrium is low,
with small foci of increased
signal intensity due to focal
adenomyosis.

recurrent pregnancy loss
shows a septate uterus. The
external fundal contour is
almost flat. The upper part of
the septum is muscular,
showing signal intensity similar
to that of the myometrium,
whereas the distal septum
is fibrous showing low signal
intensity. (Right) Axial T2WI
extension of the septum
into the cervix.

same patient shows separation
of the upper vagina into 2
compartments by a vertical
septum . (Right) Axial
shows extension of the septum
into the lower vagina,
resulting in 2 symmetrical
hemivaginas . The presence
of septate uterus, 2 cervices,
and a complete vertical vaginal
septum is a rare anomaly.
2
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SEPTATE UTERUS
Uterus
year-old woman shows a right
uterine horn with normal
endometrial:myometrial ratio
anatomy. Part of a distended left
vagina is seen. There is also a
complex left adnexal cystic mass
same patient shows a distended
left uterine horn connected
to a distended cervix . Note
the almost flat external fundal
contour .

same patient shows high signal
intensity of the contents of the
left uterine horn due to blood
contents (hematometra). The
left adnexal structure also
shows high signal intensity due
to endometriosis. (Right) Axial
shows a markedly distended
left hemivagina and a
decompressed right hemivagina
containing ultrasound gel.

same patient shows high signal
intensity of the contents of the
left hemivagina due to blood
accumulation. (Right) Sagittal
shows a markedly distended
left hemivagina and a
distended left uterine horn
(hematometrocolpos) resulting
from a lower vaginal transverse
septum . The left kidney was
absent. This case resembles
Herlyn-Werner-Wunderlich
syndrome, described with uterus
didelphys, but with definite
septate uterus.
2
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Uterus ARCUATE UTERUS
Key Facts
Terminology • Bicornuate uterus
• Class VI müllerian duct anomaly (MDA) • Submucosal leiomyoma
Imaging Pathology
• Convex, flat, or slightly concave external fundal • Near-complete resorption of uterovaginal septum
contour
Clinical Issues
• Mild focal thickening of fundal myometrium • Usually asymptomatic
• Mild indentation of fundal endometrium • Accounts for 20% of MDAs
• Hysterosalpingography (HSG) • Rarely recurrent pregnancy loss
o No defining depth of indentation to differentiate
arcuate configuration from broad septum • Good reproductive outcome if ratio of < 10% between
• 3D TVUS and MR are best modalities for uterine height of fundal indentation and distance between
lateral apices of horns
•
evaluation
o Oblique imaging performed parallel to long axis of Expectant management
o Hysteroscopic correction may be considered in
uterus
selected patients with recurrent pregnancy loss who
Top Differential Diagnoses have prominent or broad configuration of fundal
• Septate uterus myometrium
(Left) Graphic of an arcuate

uterus shows mild thickening
of the fundal myometrium
causing a broad, smooth
indentation on the endometrial
cavity . (Right) Axial
transabdominal pelvic
ultrasound obtained parallel
to the long axis of the uterus
shows a single endometrial
cavity with prominent fundal
myometrium causing
broad-based indentation of
the endometrium. The external
fundal contour is slightly
convex .

MR obtained parallel to
the long axis of the uterus
shows a single endometrial
cavity with prominent fundal
myometrium causing
broad-based indentation of
the endometrium. The external
fundal contour is flat .
(Right) Hysterosalpingogram
(HSG) shows broad fundal
indentation . A ratio of <
10% between the height of
the fundal indentation (H)
and the distance between the
lateral apices of the horns (L)
on HSG images correlates
with favorable reproductive
2 outcome.
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ARCUATE UTERUS
Uterus
TERMINOLOGY Bicornuate Uterus
Definitions
• Fundal cleft > 1 cm
• Class VI müllerian duct anomaly (MDA) based Submucosal Leiomyoma
on Buttram & Gibbons and American Society for • Distortion/displacement of junctional zone on MR
o Originally classified by Buttram & Gibbons as a
PATHOLOGY
subclass of bicornuate uterus
o Later recognized as a separate entity in American General Features
Society for Reproductive Medicine revision
▪ Due to presence of normal external fundal contour
• Etiology
o Near-complete resorption of uterovaginal septum
IMAGING CLINICAL ISSUES

General Features Presentation
• Best diagnostic clue • Most common signs/symptoms
o Uterine external fundal contour is flat, convex, or o Usually asymptomatic
mildly concave (≤ 1 cm) o Rarely recurrent pregnancy loss
o Mild focal thickening of fundal myometrium
o Mild indentation of fundal endometrium Demographics
• Morphology • Epidemiology
o Smooth, broad focal midline thickening of o Accounts for 20% of MDAs
fundal myometrium with minor indentation on o Affects 3.9% of all women
endometrial cavity
o External fundal contour is convex, flat, or has minor
cleft measuring ≤ 1 cm • Generally compatible with normal term gestations;
o Normal thickness of junctional zone delivery rate of 85%
• Good reproductive outcome if ratio of < 10% between
Hysterosalpingography (HSG) height of fundal indentation and distance between
• Single opacified endometrial cavity with broad, saddle- lateral apices of horns
shaped indentation at uterine fundus
o No defining depth of indentation to differentiate
Treatment
• Expectant management
• Hysteroscopic correction may be considered in
arcuate configuration from broad septum
CT Findings selected patients with recurrent pregnancy loss who
• Not routinely utilized for imaging of MDA have prominent or broad configuration of fundal
myometrium
MR Findings
• T2WI DIAGNOSTIC CHECKLIST
o Smooth, broad fundal indentation of endometrial
complex, isointense to myometrium Image Interpretation Pearls
o No low signal intensity fibrous component present
o Convex, flat, or slightly concave external fundal • Mild focal thickening of fundal myometrium with
convex, flat, or slightly concave fundal external
contour
contour
• Normal external uterine fundal contour SELECTED REFERENCES
o 3D US of uterus improves depiction of external
fundal contour
• Subtle, focal duplication of echogenic endometrial 2.
Marcal L et al: Mullerian duct anomalies: MR imaging.
complexes on transverse plane at level of fundus
•
Abdom Imaging. 36(6):756-64, 2011
Smooth, broad fundal indentation, isoechoic to 3. Bermejo C et al: Three-dimensional ultrasound in the
myometrium diagnosis of Müllerian duct anomalies and concordance
with magnetic resonance imaging. Ultrasound Obstet
• Best imaging tool
Gynecol. 35(5):593-601, 2010
4. Mucowski SJ et al: The arcuate uterine anomaly: a critical
o 3D TVUS and MR appraisal of its diagnostic and clinical relevance. Obstet
Gynecol Surv. 65(7):449-54, 2010
5. Chandler TM et al: Mullerian duct anomalies: from
DIFFERENTIAL DIAGNOSIS diagnosis to intervention. Br J Radiol. 82(984):1034-42,
2009
Septate Uterus 6. Mueller GC et al: Müllerian duct anomalies: comparison of
• Interface between fundal myometrium and MRI diagnosis and clinical diagnosis. AJR Am J Roentgenol.
endometrium is more angular in septate uterus and 189(6):1294-302, 2007
broad based and blunt in arcuate uterus 7. Troiano RN et al: Mullerian duct anomalies: imaging and
clinical issues. Radiology. 2004
2
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Uterus DES EXPOSURE
Key Facts
Terminology • Uterine hypoplasia
• Class VII müllerian duct anomaly based on Buttram • Arcuate/partial septate uterus
& Gibbons and American Society for Reproductive
Pathology
• Diethylstilboestrol (DES) is a synthetic estrogen
Medicine revision
Imaging o Introduced in 1948 and discontinued in 1971 due to
• T-shaped configuration of endometrial cavity teratogenic effects
o Most common manifestation: Seen in 31% of cases • 1.0-1.5 million offspring exposed in utero
• Small, hypoplastic uterus with constriction bands • ↑ incidence of benign vaginal adenosis: 67%
• Narrowed endometrial fundal segment and widened • ↑ incidence of clear cell carcinoma of vagina (0.14-1.4
lower uterine segment per 1,000 women exposed)
• Irregular endometrial margins
Clinical Issues
• Cervical hypoplasia, or stenosis (25%)
• Infertility (fertility rate of ~ 65%)
• Short fallopian tubes with sacculations and fimbrial
• ↑ risk of adverse obstetric outcomes
deformities and stenosis
Top Differential Diagnoses • Hysteroscopic metroplasty for small uteri in patients
• Asherman syndrome with primary infertility
(Left) Illustration shows

the typical appearance of
a T-shaped uterus. (Right)
Frontal image obtained during
hysterosalpingogram (HSG)
shows the typical appearance
of T-shaped uterus in a patient
with history of uterine DES
exposure. The uterus is small
with a widened lower uterine
segment , a narrowed
fundal endometrial canal ,
and irregular endometrial
margins.
(Left) Frontal image obtained

during HSG shows the
typical appearance of a T-
shaped uterus in a patient
with history of uterine DES
exposure. The uterus is small
with widened lower uterine
segment , a narrowed
fundal endometrial canal ,
and irregular endometrial
margins. (Right) 3D ultrasound
in a 42-year-old woman shows
a T-shaped endometrial stripe
with widened and elongated
lower uterine segment and
a narrowed fundal endometrial
canal .
2
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DES EXPOSURE
Uterus
TERMINOLOGY Uterine Hypoplasia
• Small uterine remnant ± small endometrial cavity
Definitions • ↓ intercornual distance in uterine hypoplasia
• Class VII müllerian duct anomaly based on Buttram
& Gibbons and American Society for Reproductive Arcuate/Partial Septate Uterus
Medicine revision • Mild focal thickening of fundal myometrium with
• Due to in utero exposure to diethylstilboestrol (DES) fused external uterine contour in arcuate uterus
• Fundal indentation of myometrium is more extensive
± small caudal fibrous component in septate uterus
IMAGING
General Features PATHOLOGY
• Best diagnostic clue General Features
o T-shaped configuration of endometrial cavity
o Myometrial constriction bands • Etiology
• Morphology o DES is a synthetic estrogen
▪ Introduced in 1948 and discontinued in 1971 due
o Uterine corpus
▪ T-shaped configuration of endometrial cavity to teratogenic effects
– Most common manifestation; seen in 31% of o Prescribed for women with recurrent spontaneous
cases abortions and poor reproductive outcomes
▪ Small, hypoplastic uterus with constriction bands o 1.0-1.5 million offspring exposed in utero
▪ Narrowed endometrial fundal segment and o Structural abnormalities also depend on amount of
widened lower uterine segment DES given to pregnant mother
▪ Irregular endometrial margins o Similar spectrum of morphologic changes reported
o Uterine cervix without history of DES exposure
▪ Hypoplasia or stenosis (25%) ▪ Suggests this may represent a rare müllerian
▪ Anterior ridge and "collar" anomaly that becomes expressed following in
▪ Pseudopolyps utero exposure to DES
o Fallopian tubes: Short with sacculations and fimbrial • Associated abnormalities
deformities o ↑ incidence of benign vaginal adenosis: 67%
o ↑ incidence of clear cell carcinoma of vagina
Hysterosalpingography (HSG) (0.14-1.4 per 1,000 women exposed)
• Cannulation of endocervical canal may be difficult due o Not associated with ↑ prevalence of renal
to cervical hypoplasia or stenosis abnormalities
• Uterine abnormalities detected in 69%
o Narrow, irregular, opacified endocervical canal with
characteristic T shape CLINICAL ISSUES
o Constriction bands, often mid fundal
o Bands cause narrowing of interstitial segments of
• Infertility (fertility rate of ~ 65%)
•
fallopian tubes
Fallopian tubes are short with irregular contours • ↑ risk of adverse obstetric outcomes
o 9x ↑ risk of ectopic pregnancy
MR Findings o 2x ↑ risk of spontaneous abortion (can occur in 1st or
• T2WI 2nd trimester)
o 3x ↑ risk of premature birth
o T-shaped configuration: Narrowing of vertical and
horizontal limbs of endometrial cavity Treatment
o Constriction bands: Focal thickening of junctional
zone → small indentations on endometrial cavity
• Cervical cerclage in patients with history of 2nd
Ultrasonographic Findings trimester losses and preterm births
• Grayscale ultrasound • Hysteroscopic metroplasty for small uteri in patients
o Findings are often difficult to characterize with primary infertility
o Small uterus with markedly short cervix
o Thin and narrow endometrial stripe
• Pulsed Doppler
o ↑ uterine arterial pulsatility index reflects ↓ uterine Consider
perfusion • Consider DES-exposed uterus in a female patient
presenting with infertility or spontaneous abortions
with history of in utero exposure to DES
Asherman Syndrome SELECTED REFERENCES
• Intrauterine synechiae or adhesions
• Nondistensible endometrial cavity on HSG with
multiple filling defects of variable size 2. Olpin JD et al: Imaging of Müllerian duct anomalies. Clin
• Low signal intensity fibrous adhesions on T2WI Obstet Gynecol. 52(1):40-56, 2009 2
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Uterus CONGENITAL UTERINE CYSTS
Key Facts
Terminology • Best imaging modality
• Congenital cyst originating from müllerian or wolffian o MR or CT with sagittal reformats
duct remnants, which is of mesodermal origin Top Differential Diagnoses
Imaging • Pedunculated uterine fibroids
• Best diagnostic clue • Uterine adenomyotic cysts
o Simple pelvic cyst embedded in myometrium or • Noncommunicating horn of bicornuate uterus
attached to uterine fundus with stalk • Paraovarian cyst
• Location
Clinical Issues
o Müllerian cysts are usually located in midline
o Wolffian duct cysts are usually located in lateral • Usually asymptomatic
uterine wall • Exceedingly rare
• CT • Commonly present during reproductive age
o Simple fluid density cyst • Almost all are benign
• MR • Laparoscopic resection, if symptomatic
o Simple fluid signal intensity
• US
o Simple anechoic cyst
(Left) Sagittal transvaginal

ultrasound shows a simple
anechoic cystic structure
related to the uterine fundus
. The cyst was not related to
the ovaries and was thought to
represent a paraovarian cyst.
The uterine attachment of the
cyst was not visualized on US.
(Right) Axial CECT shows a
midline cystic structure
attached to the uterus by a
fundal stalk .

patient shows the midline
cystic structure and the
long stalk wrapping around
the cyst. (Right) Sagittal CECT
the anterior midline cystic
structure attached to the
uterine fundus by a stalk .
2
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CONGENITAL UTERINE CYSTS
Uterus
o Cyst should not be connected to endocervical
TERMINOLOGY
glands, and lining should differ from endocervical
Definitions epithelium
• Congenital cysts originating from müllerian or o Cyst should be located in myometrium, midline or
wolffian duct remnants lateral
o Cyst should be lined by cuboidal or columnar
epithelium ± cilia and be either of low papillary type
IMAGING resembling paramesonephric duct or of smooth type
General Features resembling mesonephric duct
o Cyst wall should be partly composed of myometrium
• Best diagnostic clue • Immunohistochemical staining is usually positive to
o Simple pelvic cyst embedded in myometrium or
Wilms tumor gene and estrogen receptors, and negative
attached to uterine fundus with stalk
• Location
to CD10
o Müllerian cysts are usually located in midline Gross Pathologic & Surgical Features
o Wolffian duct cysts are usually located in lateral • During surgery, müllerian cyst of uterus usually appears
uterine wall as lobulated pedunculated cyst arising from uterine
• Size serosa, containing viscous or clear fluid
o Varies from 0.5-20 cm
CT Findings CLINICAL ISSUES

• Simple fluid density cyst Presentation
MR Findings • Most common signs/symptoms
• T1WI o Usually asymptomatic
o Homogeneous low signal intensity o May present as a palpable mass
• T2WI Demographics
o Homogeneous high signal intensity
• Age
Ultrasonographic Findings o Commonly present during reproductive age
• Simple anechoic cyst • Epidemiology
o May be difficult to visualize uterine attachment o Exceedingly rare
• Normal ovaries Natural History & Prognosis
Imaging Recommendations • Almost all are benign
• Best imaging tool o One report on carcinoma arising from müllerian cyst
o MR or CT with sagittal reformats
Treatment
• Laparoscopic resection if symptomatic
Pedunculated Uterine Fibroids SELECTED REFERENCES
• Usually solid with MR features characteristic of uterine 1. Lui MW et al: Mullerian cyst of the uterus misdiagnosed
leiomyomas as ovarian cyst on pelvic sonography. J Clin Ultrasound.
• Cystic degeneration may occur; however, there should 2.
42(3):183-4, 2014
Nakae H et al: Müllerian cyst of the uterus treated with
still be a rim of solid tumor surrounding cyst
laparoscopy and diagnosed using immunohistology. J
Uterine Adenomyotic Cysts Obstet Gynaecol Res. 39(1):430-3, 2013
• High signal intensity on T1WI 3. Protopapas A et al: Cystic uterine tumors. Gynecol Obstet
Invest. 65(4):275-80, 2008
Noncommunicating Horn of Bicornuate Uterus 4. Prasannan-Nair C et al: A benign Mullerian cyst of the
• Small banana-shaped uterine horn uterus. J Obstet Gynaecol. 27(5):537-8, 2007
• High signal intensity of contents of 2nd horn on T1WI 5. Gowri V et al: Benign mullerian type cyst of the uterus in a
perimenopausal woman. Saudi Med J. 24(12):1400-1, 2003
Paraovarian Cyst 6. Sherrick JC et al: Congenital intramural cysts of the uterus.
• Should be in vicinity of ovary with no visible Obstet Gynecol. 19:486-93, 1962
attachment to uterus
PATHOLOGY
General Features
• Criteria for congenital uterine cyst by Sherrick and
Vega
o Cyst should not communicate with uterine cavity or
be lined by endometrium
2
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Uterus ASHERMAN SYNDROME, ENDOMETRIAL SYNECHIAE
Key Facts
Terminology • HSG or sonohysterogram (SHG) are best imaging
• Permanent adherence of uterine walls, with partial or modalities for evaluation of uterine adhesions
complete obliteration of uterine cavity and clinical Top Differential Diagnoses
symptoms including menstrual abnormalities,
• Endometrial polyp
infertility, and recurrent pregnancy loss
• Endometrial blood clot
Imaging • Submucosal leiomyoma
• Complete obliteration of endometrial cavity at internal Pathology
os of cervix or lower uterine segment in severe cases
• Small linear defect to large clefts within cavity • Endometrial trauma to basalis layer, which induces
• Irregular, angulated filling defects that distort uterine scarring during healing, and localized fusion of
portions of uterine wall
•
cavity during hysterosalpingogram (HSG), sharply
defined because uterine walls are adhesed, and contrast Most common from trauma due to prior pregnancy
material cannot surround defects and dilation and curettage
• Loss of normal high signal intensity of endometrium, Clinical Issues
with obliteration of endometrial cavity, replaced by
dark T2 fibrous adhesions
• Menstrual abnormalities, infertility, recurrent
pregnancy loss
(Left) Oblique view from HSG

shows a long linear filling
defect spanning from the
fundus of the uterine cavity
to the lower uterine segment.
This represents a large scar,
which divides the cavity.
(Right) AP view of endometrial
cavity during an HSG shows
a large filling defect void of
any contrast centrally .
Note the irregular contour and
narrowing of the right uterine
cornua corresponding to the
synechiae , which obstructs
flow of contrast into the right
tube.
(Left) Axial T2WI FS MR shows

obliteration of the normal
hyperintense endometrial
cavity of the right uterine
horn , which is replaced by
dark T2 signal corresponding
to a large scar. (Right) Axial
sonohysterogram shows an
echogenic band with
the distended uterine cavity.
Another area of more rounded
scarring is also present.
2
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ASHERMAN SYNDROME, ENDOMETRIAL SYNECHIAE
Uterus
TERMINOLOGY DIFFERENTIAL DIAGNOSIS
Synonyms Endometrial Polyp
• Intrauterine adhesions (IUAs) • Polypoid mass protrudes and distends endometrial
• Uterine synechiae canal
Definitions
• Injected contrast will surround smooth, round mass
• Permanent adherence of uterine walls, with partial or Endometrial Blood Clot
complete obliteration of uterine cavity and clinical • Filling defect of variable morphology
symptoms including menstrual abnormalities, • May be mobile during HSG or SHG
infertility, and recurrent pregnancy loss
Submucosal Leiomyoma
IMAGING
• Round mass protrudes into and distends endometrial
canal
General Features
• Best diagnostic clue PATHOLOGY
o Irregular, angulated filling defects that distort uterine
General Features
• Etiology
cavity during hysterosalpingogram (HSG)
▪ Sharply defined because uterine walls are adhesed
o Endometrial trauma to basalis layer, which induces
together
– No contrast able to surround defects scarring during healing, and localized fusion of
• Location portions of uterine wall
▪ Minor scarring can affect only a small area of
o Endometrial cavity
▪ Adhesions may be centrally or peripherally located uterine wall, or scarring can be extensive, with
▪ Complete obliteration of endometrial cavity at diffuse involvement and obliteration of much of
internal cervix or lower uterine segment in severe uterine cavity
▪ Most common from trauma due to prior pregnancy
cases
• Size or from prior dilation and curettage
▪ Less common due to prior surgery
o Can range from small linear defect to large clefts
– Such as cesarean section, myomectomy,
within cavity
• Morphology
diagnostic curettage, pelvic irradiation,
endometrial necrosis from uterine artery
o Filling defects are irregular, angulated, and have
embolization, intrauterine contraceptive device,
sharp contours tubercular endometritis, and septic abortion
Hysterosalpingogram (HSG) o Postpartum uterus predisposed to develop adhesions
• Multiple, intracavitary filling defects of variable sizes ▪ Related to temporary hypoestrogenic state
▪ Increased fragility of uterine lining and likelihood
• Lack of or incomplete communication between cornua of damage during curettage
and cervical canal due to adhesions
▪ Curettage between 2nd and 4th week post partum
MR Findings is most likely to cause adhesions
• T2WI • Associated abnormalities
o Low signal intensity fibrous adhesions o Rarely associated with deep adenomyosis and
o Loss of normal, endometrial high signal intensity, placenta accreta
with obliteration of endometrial cavity
• T1WI C+ Gross Pathologic & Surgical Features
• Formation of fibrous adhesions and endometrial
o Adhesions will enhance, especially in early phase
sclerosis involving uterine cavity and sometimes
after contrast administration
Ultrasonographic Findings • Most commonly, patients have multiple adhesions that
• Grayscale ultrasound bridge anterior and posterior uterine walls
o IUAs appear as eccentric echogenic areas, rarely have • Evolve from thin endometrial strands to thick fibrous
calcifications bands
• Sonohysterogram (SHG) Microscopic Features
o Echogenic bands traversing distended endometrial
canal extending from side-to-side of uterine wall
• Avascular strands of fibrous tissue with varying
amounts of white cell infiltration
Imaging Recommendations • Some patients have no adhesions but only sclerotic,
• Best imaging tool atrophic endometrium
o HSG and SHG
• Protocol advice CLINICAL ISSUES
o Document involvement of cornual areas, upper/
lower uterine cavity, and cervix Presentation
o Document size and number • Most common signs/symptoms
o Must be present on every film to distinguish o Menstrual abnormalities (secondary amenorrhea,
synechiae from polyps irregular menses, or dysmenorrhea) 2
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o Infertility, recurrent pregnancy loss, or premature

delivery
o Abdominal pain, dyspareunia Consider
• Other signs/symptoms • Suspect diagnosis in patient with secondary
o May be asymptomatic, and pelvic examination does amenorrhea and history of postpartum hemorrhage or
not reveal abnormalities post dilation and curettage
Demographics Image Interpretation Pearls
• Epidemiology • Irregular, sharp filling defects with partial or complete
o Prevalence of IUA difficult to determine obliteration of uterine cavity on HSG
▪ 4-23% in women with postpartum bleeding • US &/or MR to image uterine cavity above adhesions
▪ 5-39% in women with recurrent miscarriages and demonstrate remnants of normal endometrium
▪ 68% of women with secondary infertility who have
history of ≥ 2 uterine curettages SELECTED REFERENCES
Natural History & Prognosis 1. Gizzo S et al: Secondary amenorrhea in severe Asherman's
• If untreated, natural history of adhesions is unknown syndrome: step by step fertility retrieval by Bettocchi's
o Spontaneous resolution and successful pregnancies hysteroscope: some considerations. Minim Invasive Ther
have been reported Allied Technol. 23(2):115-9, 2014
o Adhesive process may be progressive 2. Sadow CA et al: Imaging female infertility. Abdom Imaging.
•
39(1):92-107, 2014
Patients with atrophic endometrium have extremely 3. Vancaillie TG et al: Asherman's syndrome. Aust Nurs J.
poor prognosis 20(8):34-6, 2013
• If no endometrial proliferation after high-dose estrogen 4. Myers EM et al: Comprehensive management of severe
therapy, suspect complete obliteration by muscular Asherman syndrome and amenorrhea. Fertil Steril.
adhesions or endometrial sclerosis, and no further 97(1):160-4, 2012
surgery recommended 5. Schankath AC et al: Hysterosalpingography in the workup
• After 1 hysteroscopic treatment, 90% of patients have of female infertility: indications, technique and diagnostic
findings. Insights Imaging. 3(5):475-83, 2012
normal follow-up hysteroscopy or HSG
6. Tuuli MG et al: Uterine synechiae and pregnancy
o Most others need 2nd procedure; few women need
complications. Obstet Gynecol. 119(4):810-4, 2012
3-5 operations 7. Acholonu UC et al: Hysterosalpingography versus
sonohysterography for intrauterine abnormalities. JSLS.
Treatment
• Options, risks, complications
15(4):471-4, 2011
8. Marasinghe JP et al: Risk of synechiae following uterine
o Aims are to restore normal size and shape of uterine compression sutures. BJOG. 118(8):1020-1; author reply
cavity by removing adhesions and preventing 1021-2, 2011
formation of new adhesions 9. March CM: Asherman's syndrome. Semin Reprod Med.
▪ Uncover functional endometrium and make 29(2):83-94, 2011
10. Poujade O et al: Risk of synechiae following uterine
pregnancy possible
compression sutures in the management of major
▪ Even when satisfying anatomical result is obtained,
postpartum haemorrhage. BJOG. 118(4):433-9, 2011
normal endometrial function not guaranteed 11. Dawood A et al: Predisposing factors and treatment outcome
o Lysis of adhesions under direct vision with of different stages of intrauterine adhesions. J Obstet
hysteroscopy is safest, least traumatic, and most Gynaecol Can. 32(8):767-70, 2010
precise method 12. Deans R et al: Review of intrauterine adhesions. J Minim
▪ Other methods: Surgical reconstruction of uterine Invasive Gynecol. 17(5):555-69, 2010
cavity (vaginal route or abdominal hysterotomy), 13. Heinonen PK: [Intrauterine adhesions--Asherman's
syndrome.] Duodecim. 126(21):2486-91, 2010
curettage, adhesiolysis with electrosurgery, laser, or
14. Steinkeler JA et al: Female infertility: a systematic approach
intrauterine balloon to radiologic imaging and diagnosis. Radiographics.
▪ Laparoscopy and intraoperative ultrasound used to 29(5):1353-70, 2009
define pelvic anatomy and monitor treatment 15. Al-Serehi A et al: Placenta accreta: an association with
o Following hysteroscopic treatment fibroids and Asherman syndrome. J Ultrasound Med.
▪ IUD frequently placed in uterine cavity and 27(11):1623-8, 2008
retained for 2 months, reduces chance of 16. Berman JM: Intrauterine adhesions. Semin Reprod Med.
adherence 26(4):349-55, 2008
▪ High-dose sequential estrogen-progestin treatment 17. Lo ST et al: Endometrial thickness measured by ultrasound
scan in women with uterine outlet obstruction due to
stimulates endometrium so scarred surfaces are intrauterine or upper cervical adhesions. Hum Reprod.
reepithelialized
•
23(2):306-9, 2008
Post-treatment complications 18. Yu D et al: Asherman syndrome--one century later. Fertil
o Perforation, hemorrhage, residual intrauterine Steril. 89(4):759-79, 2008
synechia, infertility 19. Knopman J et al: Value of 3D ultrasound in the management
of suspected Asherman's syndrome. J Reprod Med.
52(11):1016-22, 2007
20. Imaoka I et al: MR imaging of disorders associated with
female infertility: use in diagnosis, treatment, and
management. Radiographics. 23(6):1401-21, 2003
2
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Uterus
(Left) Sagittal T2WI FSE MR
through the miduterine cavity
shows loss of the normal T2-
hyperintense signal of the
endometrial cavity and replaced
by dark T2 signal corresponding
to a large central scar . (Right)
Axial T2WI FS MR in the same
patient shows near-complete
obliteration of the normal T2-
hyperintense endometrial cavity
of the right uterine horn ,
which is replaced by dark T2
signal corresponding to large
synechiae. Note only a thin sliver
of normal endometrium on the
right.
(Left) AP view from HSG shows

marked distortion and lack of
distension of the uterine cavity,
with only an irregular thin lower
uterine cavity opacified .
Hysteroscopy proved to be
extensive scarring and adhesions.
(Right) AP view of endometrial
cavity on HSG shows a long
linear filling defect spanning
from the uterine fundus to
the lower uterine segment
, corresponding to a large
adhesion in this patient who
underwent dilation and curettage
1 year prior.
(Left) Oblique view from an

HSG shows an irregular single
defect in the uterine body ,
confirmed to be an isolated
synechia on hysteroscopy. Note
that there is still free spillage of
contrast in the peritoneum from
normal-appearing fallopian tubes
. (Right) Longitudinal image
from transvaginal ultrasound
shows linear echogenic bands
traversing the endometrial
cavity, corresponding to linear
synechiae and confirmed on
hysteroscopy.
2
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Uterus ENDOMETRITIS
Key Facts
• Polymicrobial infection originates from ascending • Postpartum endometritis is usually polymicrobial and
spread of infecting organisms through cervix and into involves anaerobes
uterus • Risk factors for endometritis
o Gonococcal and chlamydial infection, longstanding
Imaging
• Increasing fluid and gas in endometrial cavity in
intrauterine device, recent douching, proliferative
phase of menstrual cycle, postpartum state
postpartum patient with fever and pelvic tenderness
o Results in thickening of endometrium with fluid or Clinical Issues
gas • Most common cause of fever during postpartum period
• Parametrial inflammation, ± fluid collection, ±
Diagnostic Checklist
pyosalpinx
Top Differential Diagnoses • Consider in a symptomatic or postpartum patient with
thickened endometrium and increasing air &/or fluid
• Retained products of conception (RPOC) within endometrial cavity
• Intrauterine clot and debris
• Gas in endometrial cavity
(Left) Axial CECT shows an

enlarged postpartum uterus
containing gas within
the endometrial canal. (Right)
Axial CECT lower in the pelvis
shows a distended endometrial
cavity containing high-density
fluid and gas in this
patient with postpartum
endometritis.
(Left) Axial CECT shows a

large amount of gas within
the endometrial cavity. A
polymicrobial infection was
found in this patient with
a recent cesarean section
and endometritis. Note the
small bladder flap hematoma
. (Right) Axial CECT
demonstrates an enlarged
postpartum uterus with
a distended, peripherally
enhancing endometrium
containing fluid and gas in
this patient with postpartum
endometritis.
2
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ENDOMETRITIS
Uterus
Synonyms Retained Products of Conception (RPOC)
• Endometrial infection • Echogenic endometrial mass, usually has high velocity,
low resistance flow on color Doppler US
Definitions
• Lack of increased flow does not eliminate possibility of
• Polymicrobial infection originates from ascending RPOC
spread of infecting organisms through cervix and into
uterus Intrauterine Clot and Debris
• Fluid or complex fluid collection that changes in
appearance over time
IMAGING
• Seen in 24% of cases after delivery
General Features Gas in Endometrial Cavity
• Best diagnostic clue • 21% of patients after uncomplicated vaginal delivery
o Increasing fluid and gas in endometrial cavity in have sonographic evidence of gas in endometrial cavity
postpartum patient with fever and pelvic tenderness during first 2 postpartum weeks, with no evidence of
o Imaging findings are frequently normal in endometritis
uncomplicated endometritis
• Location
PATHOLOGY
o Endometrial or endocervical canal
CT Findings General Features

• Thickened endometrium, fluid, or gas in endometrial • Etiology
cavity o Etiologic agent often never identified
• Parametrial inflammation, ± fluid collection, ± o Common causal agents in infections not related to
pyosalpinx pregnancy include Chlamydia trachomatis, Neisseria
gonorrhoeae, genital tract mycoplasmas, aerobic and
MR Findings anaerobic vaginal flora (including those involved in
• Thickened endometrial cavity, fluid, or gas in bacterial vaginosis)
endometrial cavity o Postpartum endometritis is usually polymicrobial
• Contrast-enhanced MR increases conspicuity of and involves anaerobes
parametrial fluid collections o Risk factors for endometritis: Gonococcal and
o Low signal intensity areas adjacent to enhancing
chlamydial infection, longstanding intrauterine
endometrium and myometrium device, recent douching, proliferative phase of the
• If related to uterine artery embolization (UAE) or post menstrual cycle, postpartum state
partum, may be associated with uterine enlargement
and intracavitary hematoma
o Tubo-ovarian abscess, salpingitis, pelvic fluid
Ultrasonographic Findings collections, ovarian vein thrombophlebitis
• Grayscale ultrasound Gross Pathologic & Surgical Features
o Uterus may be enlarged
▪ Patient may be tender to palpation, limiting ability
• Laparoscopy may demonstrate edema, erythema, and
purulent exudate
to perform ultrasound examination
o Thickened, heterogeneous endometrium and Microscopic Features
endometrial fluid ± internal echoes representing gas, • Acute endometritis
increasing endometrial fluid o Large numbers of neutrophils in nonbleeding
o May also see heterogeneous collections in adnexa if endometrium
associated with pelvic inflammatory disease (PID) o Aggregates of neutrophils in stroma (microabscesses),
• Color Doppler neutrophils filling and disrupting endometrial
o Increased flow in inflamed pelvic structures glands
(fallopian tubes or adnexal masses) • Chronic endometritis
o Diagnosis is based on presence of plasma cells,
macrophages, and lymphocytes; neutrophils may
also be present
o Transvaginal ultrasound
• Protocol advice CLINICAL ISSUES
o If endometrial mass is seen, it could be retained
products of conception or blood clot Presentation
o Serial examinations may be needed to distinguish
normal postpartum endometrial fluid from
o Postpartum endometritis
endometritis
▪ Enlarged tender uterus on examination
▪ Elevated white blood cell count, fever, fluid/gas in
endometrial cavity
o Clinical abnormalities on physical examination of
women with nonpostpartum endometritis 2
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Uterus ENDOMETRITIS
▪ Lower abdominal pain, dyspareunia, fever, back • Imaging is requested for patients with refractory fever
pain, and vomiting or pain to evaluate any associated complications
▪ Adnexal tenderness on bimanual examination has • Imaging findings are frequently normal in
sensitivity of 95% for histologic endometritis uncomplicated endometritis
• Other signs/symptoms
o Spectrum of disease ranges from subclinical to
fulminant sepsis • Suspect diagnosis in symptomatic or postpartum
o Frequently associated with symptoms of lower patient with increasing air in endometrial cavity or
increasing thickness of heterogeneous endometrium
genital tract infection, such as abnormal vaginal
discharge, bleeding, itching, odor
o Complications and sequelae SELECTED REFERENCES
▪ Sequelae include chronic pelvic pain, ectopic 1. Plunk M et al: Imaging of postpartum complications:
pregnancy, infertility a multimodality review. AJR Am J Roentgenol.
▪ Psychological distress due to association with 200(2):W143-54, 2013
sexually transmitted infection and potential for 2. Rodgers SK et al: Imaging after cesarean delivery: acute and
serious sequelae chronic complications. Radiographics. 32(6):1693-712,
2012
Demographics 3. Cicchiello LA et al: Ultrasound evaluation of gynecologic
• Age causes of pelvic pain. Obstet Gynecol Clin North Am.
o Any; more common in sexually active women 38(1):85-114, viii, 2011
• Gender 4. Vandermeermd FQ et al: Imaging of acute pelvic pain. Top
Magn Reson Imaging. 21(4):201-11, 2010
o Female
•
5. McEwing RL et al: Sonographic appearances of the
Epidemiology endometrium after termination of pregnancy in
o Most common cause of fever during postpartum asymptomatic versus symptomatic women. J Ultrasound
period Med. 28(5):579-86, 2009
o Increased risk with chorioamnionitis, premature 6. Vandermeer FQ et al: Imaging of acute pelvic pain. Clin
Obstet Gynecol. 52(1):2-20, 2009
rupture of membranes, prolonged labor, retained
7. Rufener SL et al: Sonography of uterine abnormalities in
products of conception, reported in 0.5% of uterine postpartum and postabortion patients: a potential pitfall of
artery embolization interpretation. J Ultrasound Med. 27(3):343-8, 2008
Natural History & Prognosis 8. Thomassin-Naggara I et al: [Imaging in pelvic inflammatory
• Postpartum 9.
disease.] J Radiol. 89(1 Pt 2):134-41, 2008
Menias CO et al: CT of pregnancy-related complications.
o Risk of endometritis Emerg Radiol. 13(6):299-306, 2007
▪ After vaginal delivery: 2-3% 10. Kitamura Y et al: Imaging manifestations of complications
▪ After elective cesarean section: 7% associated with uterine artery embolization. Radiographics.
o Risk of endometritis for nonelective cesarean section 25 Suppl 1:S119-32, 2005
is 19% in those who receive intraoperative antibiotics 11. Ghiatas AA: The spectrum of pelvic inflammatory disease.
Eur Radiol. 14 Suppl 3:E184-92, 2004
and 30% in those who do not
12. Lazebnik N et al: The role of ultrasound in pregnancy-
▪ Incidence as high as 85% in women with cesarean related emergencies. Radiol Clin North Am. 42(2):315-27,
delivery > 6 hours after membranes have ruptured 2004
• Nonpostpartum, PID patients 13. Eckert LO et al: Endometritis: the clinical-pathologic
o In study of women with suspected PID, 28% had syndrome. Am J Obstet Gynecol. 186(4):690-5, 2002
neither endometritis nor salpingitis, 17% had 14. Sam JW et al: Spectrum of CT findings in acute pyogenic
endometritis alone, and 55% had salpingitis pelvic inflammatory disease. Radiographics. 22(6):1327-34,
▪ 85% of women with salpingitis had endometritis 2002
• Prognosis of endometritis in absence of laparoscopic

15. Nalaboff KM et al: Imaging the endometrium: disease and
normal variants. Radiographics. 21(6):1409-24, 2001
signs of salpingitis remains largely undefined 16. Ebright JR et al: Non-surgical management of post-cesarean
• Potential for progression to salpingitis and subsequent endomyometritis associated with myometrial gas formation.
infertility risks warrant aggressive antimicrobial Infect Dis Obstet Gynecol. 8(3-4):181-3, 2000
therapy
Treatment
• Oral antibiotics in noncomplicated endometritis
• Parenteral therapy is necessary for patients with tubo-
ovarian abscess, pregnant, severely ill, unable to follow
treatment, or unable to tolerate oral antibiotics
Consider
• Endometritis is a clinical diagnosis
o 80% of women with persistent postpartum fever
and endometritis have complicating factors besides
2 resistant organisms that may be identified with

imaging studies and change management
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ENDOMETRITIS
Uterus
(Left) Coronal CECT in a 36-year-
old woman with endometritis
shows a distended fluid-filled
endometrial cavity .A
polymicrobial infection arising
from the cervix was confirmed
on culture. (Right) Axial CECT
longstanding IUD shows a
peripherally distended, fluid-
filled, round endometrial cavity
consistent with endometritis.
Note the associated right
pyosalpinx in this patient with
pelvic inflammatory disease.
(Left) Axial CECT in a diabetic

woman with sepsis and
endometritis demonstrates an
enlarged uterus with a distended
endometrial cavity containing
fluid and gas . Note the
adjacent parametrial stranding
and free fluid . (Right) Axial
CECT in the same patient shows
a distended uterine cavity
containing air and fluid .A
polymicrobial infection was
confirmed in this patient with
endometritis.

ultrasound image demonstrates
a thickened endometrial canal
with bright reflectors
corresponding to foci of gas in
this patient with endometritis.
(Right) Transverse color
Doppler ultrasound image
of the uterus in the same
patient shows hypervascularity
surrounding the diffusely
thickened endometrium in
this patient with endometritis.
Note the hyperemia of the
myometrium but lack of flow in
the endometrium. Polymicrobial
infection was found on culture.
2
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Uterus PYOMYOMA
Key Facts
• Suppurative leiomyoma, uterine pyomyoma • Leiomyoma with hemorrhagic infarction
• Infected leiomyoma, fibroid • Degenerated leiomyoma
Imaging • Leiomyosarcoma
• Leiomyoma with gas and internal debris, may Pathology
be heterogeneous in attenuation with regions • Post dilation and curettage
of degeneration associated with parametrial • Post partum: Vaginal or cesarean delivery
•
inflammation
• Postuterine artery embolization
Uterine
o Intramural • Postmenopausal patients secondary to ischemia
resulting from hypertension, diabetes, or
o Submucosal
atherosclerosis
o Subserosal
• Multiplanar reformation may help identify pyomyoma Clinical Issues
rupture with discontinuity of leiomyoma wall • Triadsepsis
• Leiomyoma with debris, foci of reverberation artifact o Leiomyoma
due to gas o Bacteremia
o Sepsis
(Left) Transverse ultrasound

of the pelvis demonstrates
a large echogenic mass
with internal foci of gas
producing dirty shadowing
, corresponding to gas
within an infected fibroid.
(Right) Axial CECT view of the
pelvis demonstrates a large,
necrotic fibroid containing
gas surrounded by diffuse
inflammatory stranding and
free fluid .

patient shows a large fibroid
with internal hemorrhage, gas
, and calcification. Surgical
resection demonstrated a large
pyomyoma. (Right) Axial CECT
in a patient with pyomyoma
shows an enlarged fibroid
uterus containing fluid and
mottled gas with regions of
hemorrhagic necrosis .
2
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PYOMYOMA
Uterus
o TVUS early: Heterogeneous increased echogenicity,
TERMINOLOGY
may also see echogenic foci with reverberation
Synonyms artifact (gas)
• Suppurative leiomyoma, infected leiomyoma o TVUS late: May be hypoechoic with calcified rim
o Infected fibroid (fetal head sign)
o MR: Homogeneous high signal intensity on T1WI
Definitions and low signal intensity on T2WI
• Infected leiomyoma, fibroid • Presence of gas is not synonymous with infection
Degenerated Leiomyoma
IMAGING • Heterogeneous leiomyoma
General Features o CECT: Calcified rim if calcific degeneration
o TVUS: May see shadowing echogenic foci if calcific
• Best diagnostic clue degeneration
o Gas and debris within leiomyoma in symptomatic
o MR: High and low signal intensity on T2WI
patient
o Imaging findings not specific for most types of
▪ Associated parametrial inflammation
• Location
degeneration
o Uterine Leiomyosarcoma
▪ Intramural • Patients are not septic
▪ Submucosal
▪ Subserosal
• Enlarging heterogeneous leiomyoma, may contain gas
from necrosis
• Size o CECT: Enhancing mass with irregular areas of
o Variable necrosis
• Morphology ▪ Enhancement is less than normal myometrium
o Round, may rupture o TVUS: Heterogeneous echotexture secondary to
solid, necrotic, or hemorrhagic regions
CT Findings ▪ Color Doppler with increased vascularity
• NECT o MR: Areas of necrosis and hemorrhage; cystic change
o Enlarged uterus with gas, fluid, &/or hemorrhage ▪ Enhancement is less than normal myometrium
within leiomyoma
• CECT Endometritis
o Leiomyoma with gas and internal debris, may • Confined to endometrium
be heterogeneous in attenuation with regions of • Most common cause of postpartum fever
degeneration • Variable imaging appearance
▪ Associated parametrial inflammation o Normal
o Multiplanar reformation evaluates ovariocaudal o Thickened heterogeneous endometrium, with
extent of infected fibroid intracavitary fluid or air
▪ May help identify presence of pyomyoma rupture
with discontinuity of leiomyoma wall
PATHOLOGY
• Grayscale ultrasound General Features
o Transvaginal ultrasound (TVUS) • Etiology
▪ Heterogeneous pelvic mass or discrete leiomyoma o Associated with several clinical conditions
with cystic and solid components ▪ Post dilation and curettage
▪ Leiomyoma with debris, foci of reverberation ▪ Post partum: Vaginal or cesarean delivery
artifact due to gas ▪ Ascending uterine infection
▪ Cervical stenosis
Imaging Recommendations ▪ Postuterine artery embolization
• Best imaging tool ▪ Postmenopausal patients secondary to ischemia
o Ultrasound or CT showing gas and debris within resulting from hypertension, diabetes, or
leiomyoma in symptomatic patient atherosclerosis
• Protocol advice o Mechanisms of spread
o Interpret imaging findings in light of clinical history ▪ Contiguous spread from endometrium
▪ Direct extension from adjacent bowel or adnexa
▪ Hematogenous/lymphatic spread from distant
DIFFERENTIAL DIAGNOSIS infection
Leiomyoma With Hemorrhagic Infarction Gross Pathologic & Surgical Features
• Iatrogenic: Following uterine artery embolization • Enlarged uterus
(UAE)
• Variable appearance • Gray-white friable leiomyoma
o CT: May see gas within infarcted leiomyoma; on Microscopic Features
NECT, may see areas of high attenuation (blood) • Coagulation necrosis
• Purulent inflammation 2
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Uterus PYOMYOMA
• Multiple organisms 4. Shiota M et al: Uterus-sparing myomectomy for uterine

o Streptococcus pyomyoma following cesarean section. Taiwan J Obstet
o Staphylococcus Gynecol. 52(1):140-1, 2013
5. Sirha R et al: Postnatal pyomyoma: a diagnostic dilemma.
o Proteus BMJ Case Rep. 2013
o Serratia 6. Ugurlucan FG et al: Pyomyoma after dilatation and
o Actinomyces curettage for missed abortion. Clin Exp Obstet Gynecol.
o Enterococcus 40(1):168-9, 2013
7. Deshmukh SP et al: Role of MR imaging of uterine
leiomyomas before and after embolization. Radiographics.
CLINICAL ISSUES 32(6):E251-81, 2012
8. Pinto E et al: Conservative laparoscopic approach to a
Presentation perforated pyomyoma after uterine artery embolization. J
• Most common signs/symptoms Minim Invasive Gynecol. 19(6):775-9, 2012
o Triad: Leiomyoma, bacteremia, and sepsis 9. Shukla PA et al: Pyomyoma after uterine artery
• Other signs/symptoms embolization. J Vasc Interv Radiol. 23(3):423-4, 2012
o Fever
10. Laubach M et al: Nonsurgical treatment of pyomyoma in the
postpartum period. Surg Infect (Larchmt). 12(1):65-8, 2011
o Leukocytosis 11. Liu HS et al: Subserosal pyomyoma in a virgin female:
o Endocarditis sonographic and computed tomographic imaging features.
o Thrombophlebitis Ultrasound Obstet Gynecol. 37(2):247-8, 2011
12. Shaaban HS et al: A case of staphylococcus lugdunensis
Demographics
• Age
related pyomyoma occurring after cesarean section. J Glob
Infect Dis. 3(1):101-2, 2011
o Variable 13. Abulafia O et al: Sonographic features associated with post-
▪ Reproductive-age women uterine artery embolization pyomyoma. J Ultrasound Med.
▪ Postmenopausal women 29(5):839-42, 2010
• Epidemiology 14. Chen ZH et al: Pyomyoma: a rare and life-threatening
complication of uterine leiomyoma. Taiwan J Obstet
o Rare
Gynecol. 49(3):351-6, 2010
▪ Decline in cases secondary to advent of antibiotic 15. Lee SR et al: Magnetic resonance imaging and positron
therapy emission tomography of a giant multiseptated pyomyoma
simulating an ovarian cancer. Fertil Steril. 94(5):1900-2,
• Usually develop slowly over days or weeks, especially
2010
16. Zangeneh M et al: Pyomyoma in a premenopausal woman
after delivery or dilation and curettage with fever of unknown origin. Obstet Gynecol. 116 Suppl
• If untreated, may rupture or penetrate into 2:526-8, 2010
o Abdominal cavity 17. Fletcher H et al: A woman with diabetes presenting with
o Endometrial cavity pyomyoma and treated with subtotal hysterectomy: a case
• Mortality rates approach 21-30% 18.

report. J Med Case Rep. 3:7439, 2009
Nguyen QH et al: Sonographic appearance of a postpartum
Treatment pyomyoma with gas production. J Clin Ultrasound.
• Hysterectomy or myomectomy is usually necessary 19.

36(3):186-8, 2008
Patwardhan A et al: Pyomyoma as a complication of uterine
• Aggressive antibiotic therapy fibroids. J Obstet Gynaecol. 27(4):444-5, 2007
20. Kitamura Y et al: Imaging manifestations of complications
associated with uterine artery embolization. Radiographics.
DIAGNOSTIC CHECKLIST 25 Suppl 1:S119-32, 2005
21. Mason TC et al: Postpartum pyomyoma. J Natl Med Assoc.
Consider 97(6):826-8, 2005
• Pyomyoma in woman with unexplained sepsis and 22. Sah SP et al: Pyomyoma in a postmenopausal woman: a
leiomyoma case report. Southeast Asian J Trop Med Public Health.
• 2 patient populations 36(4):979-81, 2005
o Pregnant, post partum, or post dilation and curettage 23. Rajan DK et al: Risk of intrauterine infectious complications
o Postmenopausal women after uterine artery embolization. J Vasc Interv Radiol.
15(12):1415-21, 2004
Image Interpretation Pearls 24. de Blok S et al: Fatal sepsis after uterine artery embolization
• Consider pyomyoma in septic patient with gas- 25.
with microspheres. J Vasc Interv Radiol. 14(6):779-83, 2003
Karcaaltincaba M et al: CT of a ruptured pyomyoma. AJR Am
containing leiomyoma J Roentgenol. 181(5):1375-7, 2003
26. Lin YH et al: Pyomyoma after a cesarean section. Acta Obstet
SELECTED REFERENCES Gynecol Scand. 81(6):571-2, 2002
1. Del Borgo C et al: Postpartum fever in the presence of a

fibroid: Sphingomonas paucimobilis sepsis associated with
pyomyoma. BMC Infect Dis. 13:574, 2013
2. Kobayashi F et al: Pyomayoma during pregnancy: a case
report and review of the literature. J Obstet Gynaecol Res.
39(1):383-9, 2013
3. Rosen ML et al: Pyomyoma after uterine artery
embolization. Obstet Gynecol. 121(2 Pt 2 Suppl 1):431-3,
2 2013
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PYOMYOMA
Uterus
(Left) Sagittal CECT in the same
patient shows the extent of the
pyomyoma arising from uterine
fundus. Note the heterogeneous
attenuation of gas, hemorrhage,
and fluid . (Right) Axial
noncontrast CT demonstrates a
large fibroid uterus with necrosis
and internal gas in this
patient who presented with
sepsis. Surgery confirmed a large
pyomyoma.
(Left) Axial noncontrast CT in

the same patient shows the large
heterogeneous fibroid uterus
containing internal gas in this
patient with pyomyoma. (Right)
AP view of the abdomen shows
a dense structure in the right mid
abdomen containing a triangular
focus of gas , which proved to
be a large fibroid containing gas
in a patient with pyomyoma.
(Left) Axial CECT of the

mid abdomen shows a low-
attenuation mass, which was
continuous with an enlarged
uterus that contains foci of
internal gas . The patient
underwent hysterectomy due
to neutrophilia and fever.
Surgical resection proved
it to be an infected fibroid.
large, low-attenuation fibroid
containing septations
associated with parametrial
inflammation and a small amount
of enhancing pelvic fluid .
Surgical pathology confirmed a
pyomyoma.
2
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Uterus UTERINE LEIOMYOMA
Key Facts
• Benign tumor of uterine smooth muscle cells • Adenomyoma
Imaging • Malignant uterine neoplasms
• Homogeneous, round, well-defined myometrial mass • Ovarian fibroma
• Enlarged lobulated uterus • Uterine contraction
• Intramural, subserosal, or submucosal • Broad ligament leiomyoma
• Bridging vessel sign Clinical Issues
• T2 hypointense, well defined, homogeneous • Majority are asymptomatic, 25-30% are symptomatic
• Hyperintense rim due to edema, dilated lymphatics • Abnormal uterine bleeding is most common symptom
and veins and main indication for therapy
• Homogeneous hypoechoic mass ± shadowing • Pressure effects and pain
• TAS is essential for multiple and large leiomyomas • Infertility
• MR is most accurate for diagnosis and mapping • Most common during reproductive years
o Helpful to establish uterine origin of pelvic mass • Grow in reproductive years under estrogen stimulation
o Helps select patients for invasive treatment • Regress with menopause or induced hypoestrogenemia
• Rapid growth may indicate malignant transformation
(Left) Transvaginal ultrasound

shows a hypoechoic mass
consistent with a leiomyoma
(calipers) in the left uterine
body without definite
encroachment on the
endometrial stripe . Note
intrauterine device and
associated shadowing. (Right)
3D ultrasound image shows
that the leiomyoma has
a submucosal component
that was not apparent in the
remainder of the study. IUD
is noted. 3D ultrasound
can be helpful for localization
of submucosal leiomyomas or
intramural leiomyomas with a
submucosal component.
(Left) Hysterosalpingography
shows distortion of the
endometrial cavity with
extrinsic mass effect on
the left fundal and cornual
cavity. Spill of contrast into
the peritoneum was not seen
during the study. (Right) T2WI
MR shows distortion of the
endometrial stripe by a left
uterine leiomyoma with a
50% submucosal component
corresponding to the mass
effect on the cavity noted on
HSG. Although not large, a
leiomyoma in this location
may contribute to infertility by
obstructing the fallopian tube.
2
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UTERINE LEIOMYOMA
Uterus
o Lobulated external contour of uterus
TERMINOLOGY
• T2WI
Synonyms o Most useful sequence for detecting leiomyomas
• Fibroid, fibroleiomyoma, myoma o Homogeneous, well-defined and hypointense to
myometrium
Definitions o Pseudocapsule of compressed normal myometrium
• Benign tumor of uterine smooth muscle cells o Hyperintense rim due to edema, dilated lymphatics
and veins
IMAGING • T1WI C+
o Contrast not necessary to make diagnosis
General Features o Well-marginated solid enhancing mass
• Best diagnostic clue o Variable enhancement relative to myometrium
o Homogeneous, round, well-defined myometrial mass o Enhancing halo of dilated lymphatics and veins
• Location Ultrasonographic Findings
o Intramural
▪ Most common leiomyoma location • Grayscale ultrasound
o Enlarged lobulated uterus
▪ Normal myometrium circumscribes mass
o Homogeneous hypoechoic mass ± shadowing
▪ Usually asymptomatic
o Subserosal ▪ Poor sound attenuation due to smooth muscle
▪ Originates just deep to and abuts serosa composition
o Radiations of sharp discrete shadowing
▪ Myometrium does not surround entire mass
▪ Related to interfaces between fibrous tissue and
▪ Sessile or pedunculated
▪ May grow laterally extending between leaves of smooth muscle
o Pedunculated subserosal leiomyomas may only be
broad ligament (intraligamentous leiomyoma)
▪ Usually asymptomatic, unless complicated by visualized transabdominally
torsion and painful infarction • Color Doppler
o Submucosal o Marked peripheral flow with decreased central flow
▪ Represents ~ 5% of leiomyomas or an avascular core
o May see vessels in stalk of pedunculated subserosal
▪ Originates in subendometrial myometrium
▪ Sessile or pedunculated/intracavitary leiomyoma
o Bridging vessels sign
– Stretches overlying endometrium or projects into
uterine cavity ▪ Vessels connect uterus to subserosal leiomyoma
– Pedunculated leiomyomas may prolapse through • Sonohysterosalpingography (SIS)
cervix (2.5%) o Best for evaluation of submucosal leiomyomas
▪ Although least common location, often o Accurately depicts percentage of leiomyoma
symptomatic projecting into endometrial cavity
– Have greatest influence on irregular bleeding and o Well-defined, hypoechoic, solid mass with
infertility due to proximity to mucosal lining, shadowing
thought to be physical irritant o Usually broad-based, less commonly pedunculated
• Size o Overlying layer of echogenic endometrium confirms
o Few millimeters to several centimeters subendometrial location
o Often degenerated if > 8 cm o Distortion of interface between endometrium and
• Bridging vessel sign myometrium
o Vessels connect uterus and mass Imaging Recommendations
o Helps establish uterine origin of a pelvic mass
o Useful for subserosal leiomyoma
• US is primary modality to diagnose and evaluate
o Need to perform both transabdominal (TAS) and
Radiographic Findings transvaginal sonography (TVS)
o TAS is essential for multiple and large leiomyomas
• Hysterosalpingography (HSG) ▪ Get overall uterine size and leiomyoma locations
o May see mass effect on endometrium with large
o TVS improves spatial resolution
intramural leiomyomas
o Intracavitary mass with pedunculated submucosal ▪ Pedunculated subserosal leiomyoma may be
beyond FOV, need TAS
leiomyomas
o Structures deep to leiomyomas may be obscured by
CT Findings poor sound penetration
• NECT • MR is most accurate for diagnosis of leiomyomas
o Homogeneous isodense to myometrium o Maps size, number, and location
o Enlarged uterus with contour deformity o Helpful to establish uterine origin of pelvic mass
• CECT o Not limited by FOV, can see entire uterus and fibroid
o Initially enhances less than myometrium burden
o Usually homogeneous enhancement o Ideal depiction of uterine zonal anatomy allows
fibroid localization
MR Findings o Helps select patients for invasive treatment
• T1WI
o Isointense to myometrium 2
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o Assists in surgical planning (hysterectomy vs. uterine

CLINICAL ISSUES
sparing treatment)
o Monitors treatment response Presentation
• MR angiography • Most common signs/symptoms
o Helpful to map blood supply to leiomyomas o Majority are asymptomatic
o Sagittal plane may help visualization of parasitized o Symptomatic in 25-30% of women
ovarian vessels o Abnormal uterine bleeding is most common
symptom and main indication for therapy
▪ Typical: Menorrhagia or polymenorrhea
DIFFERENTIAL DIAGNOSIS ▪ Metromenorrhagia or intermenstrual bleeding
Adenomyoma ▪ Bleeding related to location, size, and number
• MR o Pressure effects and pain
▪ Proportional to leiomyoma size
o Poorly marginated and intermediate signal on T2
o Isointense and contiguous to junctional zone ▪ May present as heaviness, a dull ache, or bloating
o Punctate T1- and T2-hyperintense foci ▪ May compress nerve supply to pelvis and legs
• Ultrasound causing back or leg pain or suprapubic pain
▪ May produce urinary symptoms, constipation, or
o Ill-defined endometrial-myometrial interface
o Echogenic striations emanating from myometrium dyspareunia from general pressure effects
▪ Acute pain can occur due to degeneration
Malignant Uterine Neoplasms ▪ Carneous degeneration, which occurs during
• Leiomyosarcomas are very rare pregnancy, can present with abdominal pain, low-
• Irregular shape and indistinct margins grade fever, and leukocytosis
• Heterogeneous signal on T2 and post contrast ▪ Pedunculated type may twist on its pedicle, torse,
• Exhibit rapid growth and metastases infarct, and necrose; may detach and become
infected
Ovarian Fibroma ▪ May experience severe dysmenorrhea during
• Fibrous adnexal mass a menstrual cycle especially when they coexist
• No normal and separate ipsilateral ovary with pelvic inflammatory disease, adhesions, or
• Lack of bridging vessel sign helps differentiate from endometriosis
o Infertility
subserosal leiomyoma
▪ Relationship with leiomyoma is controversial
Uterine Contraction ▪ Faulty implantation or compression on fallopian
• Ill-defined, intermediate signal on T2 tube by leiomyomas located near cornua
• Changes during exam ▪ Associated with spontaneous abortion, preterm
labor, placenta previa, malpresentation, or dystocia
Broad Ligament Leiomyoma ▪ Risk of placental abruption is greatest when
• Originate in broad ligament leiomyoma is subplacental in location
• No connection to uterus • Clinical profile
o Enlarged, bulky, or lobular uterus ± symptoms
o Leiomyoma is hormonally responsive
PATHOLOGY
▪ Estrogen stimulates growth of leiomyoma
General Features – Increase in size with pregnancy
• Etiology ▪ Progesterone inhibits growth of leiomyoma
o Unclear; likely multifactorial – Decrease in size after menopause
• Genetics Demographics
o No hereditary factor clearly identified
• Age
Gross Pathologic & Surgical Features o Most common during reproductive years
• Well-defined, pseudoencapsulated mass within • Ethnicity
myometrium o African American women have increased incidence
• Spherical, firm, white, and elastic in consistency and more severe disease
• Ranges in size from several millimeters to many • Epidemiology
centimeters o Most common uterine neoplasm
▪ 40% of women > 35 years
Microscopic Features o African Americans
• Uniform, anastomosed, and whorled smooth muscle ▪ 2-3x greater risk compared with Caucasians
cells ▪ Disproportionately affected by more multiple and
• Variable amounts of fibrous connective tissue larger leiomyomas
• Small, infrequent blood vessels o Present in as many as 80% of women by age 50
• No significant mitosis, atypia, or necrosis
2
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UTERINE LEIOMYOMA
Uterus
o Account for 1/3-1/2 of hysterectomies in North
America
• Grow during reproductive years under estrogen • Round, well-defined, homogeneous T2-hypointense
myometrial mass
stimulation
• Regress with menopause or induced hypoestrogenemia Reporting Tips
• Rapid unexpected growth may indicate malignant • Preembolization MR
transformation o Uterine size
o Malignant transformation is rare at 0.2-0.3% o Leiomyoma number, size, and location
• Good prognosis; most women are asymptomatic ▪ Submucosal, intramural, subserosal, cervical
• If symptomatic, most women benefit from treatment o Degree of leiomyoma enhancement/viability
• Pedunculated subserosal may become parasitic o Pedunculated leiomyomas: Report stalk diameter
o Submucosal leiomyomas: Report relationship of size/
Treatment diameter and endometrial interface
• Hysterectomy is definitive treatment (total or o Presence of adenomyosis (affects clinical success of
supracervical) embolization)
o Leiomyomas are leading indication for surgery in o Ovarian vessel parasitization
women
• Uterine sparing alternatives
SELECTED REFERENCES
o Medical therapy
▪ Gonadotropin-releasing hormone analog 1. Deshmukh SP et al: Role of MR imaging of uterine
▪ Regrowth with cessation leiomyomas before and after embolization. Radiographics.
o Myomectomy 32(6):E251-81, 2012
▪ Principal mode of treatment for those who wish to 2. Parker WH: The utility of MRI for the surgical treatment of
women with uterine fibroid tumors. Am J Obstet Gynecol.
maintain fertility 206(1):31-6, 2012
▪ 11-15% reintervention rate 3. Yoshino O et al: Decreased pregnancy rate is linked to
▪ Increasing number of leiomyomas associated with abnormal uterine peristalsis caused by intramural fibroids.
worse outcomes Hum Reprod. 25(10):2475-9, 2010
▪ Hysteroscopic removal of leiomyomas with at least 4. Verma SK et al: Submucosal fibroids becoming endocavitary
50% submucosal component following uterine artery embolization: risk assessment by
o Uterine artery embolization MRI. AJR Am J Roentgenol. 190(5):1220-6, 2008
▪ Majority of patients report improvement in 5. Goodwin SC et al: Uterine artery embolization versus
myomectomy: a multicenter comparative study. Fertil Steril.
symptoms 85(1):14-21, 2006
– 70% maintain symptom relief 5 years after 6. Madan R: The bridging vascular sign. Radiology.
▪ 80-90% successful in improving symptoms 238(1):371-2, 2006
▪ Similar success rate to myomectomy 7. Day Baird D et al: High cumulative incidence of uterine
– Fewer adverse events leiomyoma in black and white women: ultrasound evidence.
– Shorter recovery time Am J Obstet Gynecol. 188(1):100-7, 2003
– Use of fewer postoperative narcotics 8. Kido A et al: Diffusely enlarged uterus: evaluation with MR
▪ Preprocedure MR to determine eligibility and imaging. Radiographics. 23(6):1423-39, 2003
9. Razavi MK et al: Abdominal myomectomy versus uterine
exclude other causes of bleeding and pain fibroid embolization in the treatment of symptomatic
▪ Possible contraindications uterine leiomyomas. AJR Am J Roentgenol. 180(6):1571-5,
– Nonviable leiomyoma 2003
– Pedunculated leiomyoma with stalk < 2 cm 10. Davis PC et al: Sonohysterographic findings of endometrial
in diameter (risk of pedicle infarction and and subendometrial conditions. Radiographics.
leiomyoma detachment) 22(4):803-16, 2002
– Uterine or leiomyoma size > 20 cm 11. ACOG Committee on Practice Bulletins-Gynecology: ACOG
practice bulletin. Surgical alternatives to hysterectomy in
– Endometrial or adnexal neoplasm
the management of leiomyomas. Number 16, May 2000
▪ Postprocedure MR (replaces educational bulletin number 192, May 1994). Int J
– May not be necessary if asymptomatic Gynaecol Obstet. 73(3):285-93, 2001
– If persistent symptoms, can assess for residual 12. Murase E et al: Uterine leiomyomas: histopathologic
enhancement (viability) or parasitized vessels to features, MR imaging findings, differential diagnosis, and
determine if repeat embolization is needed treatment. Radiographics. 19(5):1179-97, 1999
– Evaluate for passage of leiomyoma 13. Mayer DP et al: Ultrasonography and magnetic resonance
– Normal findings include leiomyoma infarction imaging of uterine fibroids. Obstet Gynecol Clin North Am.
22(4):667-725, 1995
(lack of enhancement), hemorrhage, small
14. Karasick S et al: Imaging of uterine leiomyomas. AJR Am J
amount of gas, liquefaction, calcification Roentgenol. 158(4):799-805, 1992
o Thermoablative techniques
▪ Myolysis, cryomyolysis, laser ablation, and focused
ultrasound (FUS)
▪ Not widespread, limited by size and location
2
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shows a large solid mass
in the left uterine body. There
is a claw of myometrium
surrounding the mass
and the endometrial stripe
is displaced to the right.
Although heterogeneous, the
mass is mostly hypoechoic
with posterior acoustic
shadowing. (Right) Axial
T2WI FSE MR shows that
the mass is surrounded
by myometrium ,
circumscribed, and diffusely
hypointense to myometrium,
compatible with an intramural
leiomyoma. Distortion of the
endometrial stripe is noted.
(Left) Transverse
transabdominal ultrasound
of the uterus in a patient
with a submucosal leiomyoma
shows a centrally located
hypoechoic mass . The
endometrial stripe cannot
be identified. (Right) Axial
CECT in the same patient
shows an enhancing mass
isodense to the myometrium
and obliterating the left portion
of the endometrial stripe .
(Left) Axial T2WI FSE MR

obtained in the same patient
better demonstrates the > 50%
submucosal component of
the leiomyoma . Note the
normal hyperintense signal
of the endometrial stripe
encasing much of the mass.
(Right) Axial oblique T2WI FSE
MR shows the well-defined
hypointense submucosal
leiomyoma protruding into
the endometrial cavity.
The increased endometrial
interface to leiomyoma
diameter is important to report
if this patient is to undergo
uterine artery embolization
2 (UAE).
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UTERINE LEIOMYOMA
Uterus
(Left) Axial T2WI FSE MR shows
a solid mass in the right
pelvis abutting the uterus with
multiple intervening flow voids
. Note the normal right ovary
located posterior to and
separate from the mass. (Right)
Axial T1WI C+ FS MR shows
the mass and the surrounding
claw of myometrium . This
is compatible with a viable
subserosal leiomyoma with the
bridging vessels confirming
the uterine orgin.

shows a hypoechoic solid mass
centered in the uterus and
obscuring the endometrial stripe.
(Right) Sonohysterogram in the
same patient shows a lobular
hypoechoic solid mass with
posterior acoustic shadowing.
There is a thin echogenic layer
of endometrium overlying
the mass and confirming its
subendometrial location,
compatible with a leiomyoma.
Sonohysterosalpingography
(SIS) accurately depicts the >
50% submucosal component,
indicating it is amenable to
hysteroscopic resection.

FSE MR shows a circumscribed
hypointense myometrial mass
with a < 50% submucosal
component compatible with
a leiomyoma. MR is ideal
for visualization of uterine
zonal anatomy allowing exact
localization of leiomyomas.
(Right) Sagittal T2WI FSE MR
the typical leiomyoma
anteriorly juxtaposed to a typical
adenomyoma posteriorly. In
contrast to the leiomyoma, the
adenomyoma is intermediate
in signal with multiple internal
hyperintense foci .
2
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Uterus DEGENERATED LEIOMYOMA
Key Facts
Imaging • MR: Heterogeneous T1 and T2 signal intensity,
• Heterogeneous, well-defined uterine mass that may reflecting type and level of degeneration
• After contrast administration, degenerated fibroids
contain cystic components or coarse calcifications
o Increasing likelihood of degeneration as size of will show varied enhancement depending on type and
leiomyoma increases degree of degeneration
o 2/3 of leiomyomas show some form of degeneration • US: Well-defined myometrial mass with heterogeneous
• There are different types of leiomyomatous echogenicity
degeneration, which may be difficult to distinguish on Top Differential Diagnoses
imaging
o Hyaline degeneration • Focal adenomyosis/adenomyoma
o Cystic degeneration • Cystic adnexal mass
o Myxoid degeneration • Leiomyosarcoma
o Carneous/red degeneration • Myometrial contraction
o Hemorrhagic necrosis
Clinical Issues
• Calcification is common in degenerated leiomyomas
• Most degenerating leiomyomas are asymptomatic
• CT: Degenerated leiomyomata will show
• If symptomatic, patients may present with bleeding,
heterogeneous attenuation compared to normal
pain, mass effect
myometrium
(Left) Sagittal T2WI MR

shows a large heterogeneous
subserosal leiomyoma
arising from the anterior
fundus. There is an irregular
hyperintense cystic space ,
as well as a solid component
. Note the smaller
degenerated leiomyoma
along the anterior body .
(Right) Sagittal T1WI C+ FS
enhancement of the solid
components , whereas the
cystic spaces are avascular.
This is an example of cystic
degeneration.

heterogeneous subserosal
mass arising from
the right uterine fundus.
There is an eccentric cystic
space as well as a more
peripheral hypoenhancing
solid component. Note the
normal cervix . (Right)
Longitudinal transvaginal
shows the heterogeneous
degenerated leiomyoma
. The cystic space
appears as an irregular
hypoechoic component. As
leiomyomas increase in size,
there is a higher likelihood of
2 degeneration.
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DEGENERATED LEIOMYOMA
Uterus
TERMINOLOGY – Another possible etiology is liquefaction of
hyalinized areas due to a decreased blood supply
Synonyms ▪ When large, can mimic a cystic pelvic/adnexal
• Degenerated fibroid mass
• Degenerated fibroleiomyoma o Myxoid degeneration
▪ Degeneration with deposition of myxoid material
• Degenerated myoma – May have overt cystic components
Definitions ▪ May also be seen in leiomyosarcomas and other
• Degeneration of benign myometrial smooth muscle malignant tumors
tumor o Carneous/red degeneration
▪ Secondary to hemorrhagic infarction
– Thought to be due to obstruction of draining
IMAGING veins at periphery of lesion
General Features ▪ Degeneration related to extensive coagulation
• Best diagnostic clue necrosis that involves entire lesion
▪ Often occurs during pregnancy or with oral
o Heterogeneous, well-defined uterine mass that may
contain cystic components or coarse calcifications contraceptive therapy
o
• Location Hemorrhagic necrosis (distinct from carneous
degeneration)
o Myometrial in origin
o Pedunculated exophytic subserosal lesions will ▪ Secondary to smooth muscle injury and associated
hemorrhage
demonstrate myometrial continuity
– Muscle eventually replaced by firm collagenous
▪ Stalk may occasionally be difficult to identify
• Size
tissue
▪ Often seen after UAE
o Increasing likelihood of degeneration as size of
▪ Can also be seen in leiomyosarcomas
leiomyoma increases o Calcification is common finding in degenerated
o Degenerated leiomyomas are usually > 5-8 cm in size
leiomyomas
▪ Some degree of hyalinization is present in most
▪ Seen in up to 25% of leiomyomas
leiomyomas > 4 cm ▪ Present in 4% of cases of hyaline degeneration
o Can exceed 20 cm in diameter
▪ More common in postmenopausal patients
• Morphology ▪ Calcifications are usually dense, amorphous,
o Degenerated leiomyomas are typically round, well
dystrophic
marginated, and heterogeneous ▪ Ring-like peripheral calcification is an uncommon
▪ Level of heterogeneity depends on amount and pattern, which may represent thrombosed veins
type of degeneration from past red degeneration
o Can be single or multiple, each with varying degrees o Stromal edema is common histopathologic finding,
of degeneration but does not represent a type of degeneration
• Imaging may not be able to reliably differentiate ▪ Present in ~ 50% of leiomyomas
between types of degeneration ▪ May precede hyalinization and evolve into
• 2/3 of leiomyomas show some form of degeneration various degrees of collagen deposition and cystic
o Degeneration occurs secondary to interruption of degeneration
blood supply ▪ Most prominent at periphery of leiomyoma but
▪ Typically, when a leiomyoma outgrows its blood may be seen throughout lesion
supply o Superinfection of degenerated leiomyomata is rare
– Lesions are hormonally sensitive and can grow ▪ More common in submucosal lesions
rapidly under estrogen stimulation, often seen in ▪ Related to ascending infection
pregnancy ▪ Abscess may form centrally with associated gas
▪ Also associated with trauma and postmenopausal
atrophy Radiographic Findings
▪ Seen following uterine artery embolization (UAE) • Radiography
▪ Type of degeneration varies with degree and o Calcified degenerated leiomyomas may appear as
rapidity of onset of vascular insufficiency rounded or amorphous pelvic calcifications
o Hyaline degeneration
CT Findings
▪ Most common form of degeneration, occurring in
> 60% of leiomyomas • NECT
o Degenerated leiomyomata will show heterogeneous
▪ Accounts for classic MR signal characteristics of
leiomyomata attenuation compared to normal myometrium
▪ When advanced, may develop a fatty component ▪ Cystic portions will be of low attenuation
o Cystic degeneration ▪ Calcifications may be present
▪ Cystic spaces appear as round, well-demarcated ▪ Acute hemorrhage may be higher in attenuation
o Subserosal lesions will result in uterine contour bulge
areas containing fluid
o Uterus may appear diffusely enlarged in setting of
– Correspond to areas of necrosis
▪ Believed to be result of progressive edema and is multiple lesions
•CECT
observed in ~ 4% of leiomyomas
2
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o Regions of hyaline degeneration will have Angiographic Findings

diminished contrast enhancement
o Areas of necrosis or cystic change will not enhance
• No opacification/enhancement of necrotic or cystic
areas
MR Findings • Entire lesion may appear avascular with carneous/red
• T1WI degeneration
o Heterogeneous signal intensity (SI) reflecting type
and level of degeneration DIFFERENTIAL DIAGNOSIS
▪ Hyaline: Variable, may have high signal intensity
▪ Cystic: Low SI within cystic spaces Focal Adenomyosis/Adenomyoma
▪ Myxoid: Variable • Poorly marginated ectopic endometrial glands and
▪ Carneous/red: Variable central SI often with high stroma in myometrium
SI rim that may correspond to obstructed vein • US: Poorly defined area of abnormal heterogeneous
▪ Hemorrhagic: Diffuse increased SI echotexture in myometrium with cysts simulates cystic
▪ Calcifications will manifest as signal voids degeneration
▪ Edema: Diffuse low SI • T2WI: Focal widening of junctional zone ≥ 12 mm
• T2WI &/or ill-defined low signal intensity mass ± punctate
o Well-defined mass with heterogeneous SI reflecting bright foci
type and level of degeneration Cystic Adnexal Mass
▪ Hyaline: Heterogeneous with predominantly low
SI
• Uterus is separate from mass; there is no myometrial
continuity
▪ Cystic: High SI within cystic spaces
▪ Myxoid: Very high SI
• Can be challenging to differentiate in setting of
a pedunculated subserosal fibroid with cystic
▪ Carneous/red: Variable central SI ± low SI degeneration
peripheral rim that corresponds to obstructed
veins Leiomyosarcoma
▪ Hemorrhagic: Diffuse low SI • May contain areas of hemorrhage and necrosis
▪ Calcific components may manifest as foci of signal • Overlap in imaging features with degenerated
voids leiomyoma
▪ Edema: Irregular high SI due to accumulation of • T1WI: Variable appearance; may have hemorrhagic
fluid high SI components
• T2* GRE • T2WI: Heterogeneous, irregular, ill defined
o Foci of susceptibility reflect areas of calcification or • Secondary signs of malignancy may be present: Ascites,
blood products lymphadenopathy, peritoneal implants, invasion of
• T1WI C+ adjacent structures
o Heterogeneously enhancing mass
Pelvic or Tubo-Ovarian Abscess
▪ Regions of hyaline and myxoid degeneration
• Complex cystic adnexal mass inseparable from ovary
will show hypoenhancement when compared to
• Associated inflammatory change and ascites
• Patient will present with infectious symptoms
myometrium
▪ No enhancement of cystic/necrotic components
▪ In setting of carneous/red degeneration, entire Myometrial Contraction
lesion will not enhance
▪ With extensive edema, there is often marked
• Focal mass-like thickening of myometrium
delayed enhancement • Transient finding that resolves on subsequent imaging/
sequences
• Grayscale ultrasound PATHOLOGY
o Heterogeneous myometrial mass
▪ Hyaline degeneration will typically appear General Features
hypoechoic • Etiology
▪ Cystic degeneration will appear as anechoic areas o Benign tumors of smooth muscle origin
with posterior acoustic enhancement
▪ Hemorrhagic degeneration will manifest as Gross Pathologic & Surgical Features
hypoechoic cystic spaces with posterior acoustic • Different appearance based on type of degeneration
enhancement o Hyaline: Smooth, well-marginated, homogeneous,
▪ Calcification will appear as hyperechoic foci with translucent lesion
posterior shadowing o Myxoid: Cystic regions filled with gelatinous
• Color Doppler material
o Carneous/red: Loss of whorled appearance of cut
o Relatively avascular on Doppler or color US compared
to myometrium surface, softer consistency
o No color flow with necrosis or cystic change o Necrotic: Irregular yellow foci
2
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Uterus
o Hemorrhagic: Red foci Treatment
Microscopic Features • May be warranted in symptomatic patients
• Different features based on type of degeneration • Treatment options include
o Hyaline: Smooth muscle is replaced with collagen o Medical (GnRH analog)
demonstrating a uniform, pale, eosinophilic ground- ▪ May result in necrosis of leiomyoma
glass appearance o Surgical (hysterectomy or myomectomy)
o Myxoid: Central mucoid component containing ▪ Hysteroscopic or laparoscopic myomectomy are
hyaluronic acid-rich mucopolysaccharides less invasive
o Carneous/red: Peripheral venous thrombosis, o UAE
"ghosts" of the muscle cells, hemorrhage ▪ Treated lesions undergo hemorrhagic/coagulative
o Cystic degeneration: Variable-sized cystic spaces, necrosis and eventual hyalinization
develop in edematous acellular center
o Edema: Fluid seen in stroma of leiomyoma, often in DIAGNOSTIC CHECKLIST
association with collagen deposition
• Nondegenerated portions of leiomyoma will Image Interpretation Pearls
show typical whorled smooth muscle and fibrous • Identification of hypovascular or avascular degenerated
components with a pseudocapsule leiomyomas may help direct therapy, as these lesions
often respond poorly to UAE
CLINICAL ISSUES
SELECTED REFERENCES
Presentation
• Most common signs/symptoms 1. Han SC et al: Degeneration of leiomyoma in patients
referred for uterine fibroid embolization: incidence,
o Most degenerating leiomyomas are asymptomatic imaging features and clinical characteristics. Yonsei Med J.
o If symptomatic, patients often present with 54(1):215-9, 2013
▪ Acute pelvic pain 2. Deshmukh SP et al: Role of MR imaging of uterine
▪ Localized tenderness leiomyomas before and after embolization. Radiographics.
▪ Mild leukocytosis 32(6):E251-81, 2012
▪ Pyrexia 3. Lamarca M et al: Leiomyomatosis peritonealis disseminata
▪ Nausea and vomiting with malignant degeneration. A case report. Eur J Gynaecol
Oncol. 32(6):702-4, 2011
▪ Vaginal bleeding 4. Fogata ML et al: Degenerating cystic uterine fibroid mimics
o Risk for pain increases with larger size of leiomyoma, an ovarian cyst in a pregnant patient. J Ultrasound Med.
common in lesions > 5 cm in diameter 25(5):671-4, 2006
o Pain typically presents in late 1st or early 2nd 5. Ouyang DW et al: Obstetric complications of fibroids.
trimester, which corresponds to period of greatest Obstet Gynecol Clin North Am. 33(1):153-69, 2006
rate of leiomyoma growth 6. Semelka R: Abdominal-Pelvic MRI. 2nd ed. Hoboken: Wiley.
o Red degeneration can cause systemic symptoms and 1266-76, 2006
7. Birchard KR et al: MRI of acute abdominal and pelvic pain in
has been shown to incite premature labor
pregnant patients. AJR Am J Roentgenol. 184(2):452-8, 2005
o Large degenerated leiomyomas may present as a
8. Pelage JP et al: Uterine fibroid vascularization and clinical
palpable mass or with symptoms of mass effect/ relevance to uterine fibroid embolization. Radiographics. 25
pressure Suppl 1:S99-117, 2005
o May result in infertility 9. Bennett GL et al: Gynecologic causes of acute pelvic pain:
• Other signs/symptoms spectrum of CT findings. Radiographics. 22(4):785-801,
o Massive intraperitoneal hemorrhage due to 2002
10. Kamat NV et al: Ruptured degenerated uterine fibroid
leiomyomas
diagnosed by imaging. Obstet Gynecol. 98(5 Pt 2):961-3,
▪ Uncommon 2001
▪ Can result in systemic shock 11. Robboy SJ et al: Pathology and pathophysiology of uterine
smooth-muscle tumors. Environ Health Perspect. 108 Suppl
Demographics
• Ethnicity
5:779-84, 2000
12. Murase E et al: Uterine leiomyomas: histopathologic
o Leiomyomas are more common in black patients features, MR imaging findings, differential diagnosis, and
• Epidemiology treatment. Radiographics. 19(5):1179-97, 1999
o Leiomyomas are present in up to 50% of women 13. Ueda H et al: Unusual appearances of uterine leiomyomas:
o Up to 2/3 of leiomyomas have evidence of MR imaging findings and their histopathologic
backgrounds. Radiographics. 19 Spec No:S131-45, 1999
degeneration
14. Callen P: Ultrasonography in Obstetrics and Gynecology.
Natural History & Prognosis 3rd ed. Philadelphia: Saunders. 603-8, 1994
• Prognosis is good, as most women are asymptomatic 15. Casillas J et al: CT appearance of uterine leiomyomas.
• In pregnant patients, may result in intrauterine growth

Radiographics. 10(6):999-1007, 1990
restriction and preterm delivery when large

• Rapid unexpected growth may indicate malignant
transformation
• Rupture of degenerated leiomyoma is a rare
complication
2
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(Left) Axial CECT shows

a large heterogeneous
enhancing uterine mass ,
consistent with a degenerated
leiomyoma. (Right) Axial T1WI
the leiomyoma to be fairly
homogeneous, with the same
signal intensity as normal
myometrium.

the leiomyoma to
have heterogeneous but
predominantly low signal
intensity, most suggestive
of hyaline degeneration.
same patient again shows
the degenerated leiomyoma
. There is an irregular
hyperintense component ,
likely representing associated
edema.
(Left) Axial CECT in a

patient presenting with
infectious symptoms shows a
heterogeneous degenerated
submucosal leiomyoma
containing several foci of air.
same patient shows layering air
within the degenerated fibroid
with an associated air-
fluid level . Central necrotic
debris is noted. Infection
of a degenerated leiomyoma
is rare but more likely with
submucosal positioning and
in the setting of an ascending
infection.
2
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Uterus
a large leiomyoma with
predominantly high signal
intensity arising from the anterior
wall of the uterine body. (Right)
patient shows the leiomyoma
to be slightly heterogeneous
but predominantly isointense to
normal myometrium.
(Left) Sagittal T1WI FS MR

the leiomyoma to be
homogeneously isointense to
normal myometrium. (Right)
Sagittal T1WI C+ FS MR
heterogeneous enhancement
of the leiomyoma . These
findings, particularly the T2
hyperintensity with postcontrast
enhancement, are suggestive of
myxoid degeneration.
(Left) Axial NECT shows a

peripherally calcified mass
that appears to arise from the left
aspect of the uterus, consistent
with a degenerated leiomyoma.
Note the IUD centrally within
the uterus. (Right) Longitudinal
transvaginal ultrasound in the
same patient demonstrates a
subserosal uterine mass with
curvilinear peripheral echogenic
calcification. Note the associated
posterior shadowing .
2
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a large uterine mass
that is isointense to normal
myometrium. There is a
smaller hyperintense uterine
lesion noted as well.
(Right) Sagittal T2WI MR in
large anterior fundal mass
to be heterogeneously
hypointense, consistent with
hyaline degeneration. The
smaller fundal lesion is
hyperintense. Note the ovarian
endometriomas posterior to
the uterus.
(Left) Axial T1WI C+ FS MR

the leiomyoma with hyaline
degeneration to have
heterogeneous enhancement.
The smaller fundal lesion
shows minimal to no
enhancement. (Right) Sagittal
T1WI C+ FS MR in the
same patient shows the
enhancing leiomyoma with
hyaline degeneration . The
hypovascular fundal lesion
is suggestive of myxoid
degeneration of a smaller
leiomyoma. Note the ovarian
endometriomas .
(Left) Frontal radiograph

of the pelvis demonstrates
incidental dense rounded
calcified masses within the
central pelvis, most consistent
with calcified leiomyomata.
patient demonstrates a densely
calcified subserosal leiomyoma
along the posterior
uterine body. Calcification
is commonly seen within
degenerated leiomyomata.
2
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Uterus
(Left) Axial CECT in a patient
presenting with systemic shock
uterine mass , consistent
with a degenerated leiomyoma.
patient at a higher level shows
multiple loops of small bowel
in the left abdomen with wall
and fold thickening, suggestive of
shock bowel.
(Left) Axial T1WI FS MR in

the same patient obtained
after stabilization shows the
leiomyoma to be iso-
to slightly hyperintense to
the myometrium. There are
faint hyperintense peripheral
linear components as
well. (Right) Axial T1WI FS
MR in the same patient at the
level of the cervix shows the
leiomyoma to protrude into
the cervical canal. There is a
peripheral hyperintense rim .
The peripheral hyperintense
components may represent
blood products or thrombosed
veins.
(Left) Axial T2WI MR in

degenerated leiomyoma to be
heterogeneous in signal, and to
protrude into the endocervical
canal. (Right) Axial T1WI C+ FS
the degenerated leiomyoma
to be largely avascular and
nonenhancing. This constellation
of findings is suggestive of red/
carneous degeneration.
2
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Uterus PARASITIC LEIOMYOMA
Key Facts
• Leiomyoma that becomes adherent to surrounding • Likely arises from pedunculated subserosal myomas
structures, develops auxiliary blood supply, and loses that have completely separated from uterus and
its original attachment to uterus, thus becoming acquired a new blood supply
parasitic • Develops after laparoscopic myomectomies or
hysterectomies with use of electric tissue morcellator
Imaging
• Freely detached leiomyoma with clearly defined Clinical Issues
arterial supply from nearby structures • Prevalence of iatrogenic parasitic leiomyoma ranges
• Usually pelvic in location from 0.12-0.9% after morcellation procedures
• Features are identical to typical uterine leiomyomas • May be asymptomatic depending on size and
menstrual status
Top Differential Diagnoses • May cause pressure on adjacent organs (e.g, urethra,
• Lymphadenopathy bladder neck, ureter, rectum)
• Solid ovarian masses • Can be associated with pseudo-Meigs syndrome
• Uterine leiomyomas • Torsion may occur
• Leiomyosarcoma • Often requires surgical removal for symptomatic relief
(Left) Axial transvaginal

ultrasound in a patient 5 years
after hysterectomy shows a
solid heterogeneous pelvic
mass . (Right) Axial CECT
underwent hysterectomy for
diffuse leiomyomatosis and
presented with hydrothorax
shows a heterogeneous
midline pelvic mass and
ascites . The combination of
ascites, pleural effusion, and a
benign pelvic mass (other than
ovarian fibroma) represents
pseudo-Meigs syndrome.

year-old woman with history
of enlarged uterus due to
multiple leiomyomas shows a
left pelvic mass separate
from the uterus and left
ovary (not shown). The mass
shows homogeneously low
signal intensity relative to the
pelvic skeletal muscles. There
is a small vascular branch
that extends to the mass.
marked enhancement of the
left pelvic mass and the
small vessel supplying the
mass .
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PARASITIC LEIOMYOMA
Uterus
o Similar to typical leiomyoma with whorled
TERMINOLOGY
appearance and variable echogenicity, depending on
Synonyms extent of degeneration, fibrosis, and calcification
• Parasitic fibroid • Color Doppler
• Broad ligament leiomyoma o Absence of color flow Doppler signal does
not necessarily indicate acute torsion because
Definitions leiomyomas may show absent flow or low flow
• Leiomyoma that becomes adherent to surrounding without torsion
structures, develops auxiliary blood supply, and loses o Presence of color flow Doppler signal does not
its original attachment to uterus, thus becoming exclude intermittent torsion of parasitic leiomyoma
parasitic
PET/CT
IMAGING
• Mild or moderate uptake of FDG-18 is often observed in
uterine leiomyomas and declines with age
o Freely detached leiomyoma with clearly defined o Gadolinium-enhanced MR of pelvis is most sensitive
arterial supply from nearby pelvic or abdominal modality for defining size, location, and arterial
structures supply of a parasitic leiomyoma
o May see large draining veins
o Surgical planning relies on detailed cross-sectional
• Protocol advice
o Multiplanar pre- and post-gadolinium images with
imaging to define extent of lesion and blood supply small field of view centered over pelvis or region of
• Location interest
o Parasitic leiomyomas are almost exclusively pelvic in
location
o Common sites of attachment &/or arterial DIFFERENTIAL DIAGNOSIS
recruitment are fallopian tubes, broad ligament, and Lymphadenopathy
•
omentum
Size
• Often, there are other pathologically enlarged lymph
nodes throughout pelvis
o Variable
• Morphology Solid Ovarian Masses
o Identical in size, shape, morphology, and histology • Parasitic leiomyomas can be associated with elevated
to typical uterine leiomyomas CA125 and even pseudo-Meigs syndrome, and thus
may be mistaken for ovarian carcinoma and other
CT Findings ovarian masses
• Usually uniform, solid soft tissue attenuation similar to • Ovarian origin of a mass can be confirmed by following
normal uterine myometrium round ligament or ovarian vein
• Calcifications can be seen in 3-10% of all leiomyomas o Parasitic leiomyomas are separate from uterus and
• Contrast enhancement similar to typical leiomyomas ovaries
• CTA may help define arterial supply and venous • Ovarian fibromas and Brenner tumors may have similar
drainage of parasitic leiomyoma imaging characteristics due to fibrous content
MR Findings Uterine Leiomyomas
• T1WI • Connected to uterus with vascular stalk
o Isointense to normal myometrium, similar to typical • MR, with its multiplanar capabilities, can show the
uterine leiomyomas vascular stalk
• T2WI
Leiomyosarcoma
o Hypointense to normal myometrium, similar to
typical uterine leiomyomas • Often pathologic diagnosis
o Imaging features are not specific: Irregular margins,
o Degenerative changes are also identical to those of
necrosis, and hemorrhage may suggest diagnosis
uterine leiomyomas o Rapid increase in size in postmenopausal woman
• T1WI C+ FS o Features of aggressive invasion into surrounding soft
o Heterogeneous enhancement similar to that of
tissues
uterine leiomyomas
• MRA
o Enhancing vasculature can be traced from PATHOLOGY
leiomyoma to "parasitized" organ
▪ Often distinctly separate from normal uterine
General Features
artery • Etiology
o Pathogenesis is still uncertain
▪ May see draining veins
▪ Primary parasitic leiomyomas are extremely rare
Ultrasonographic Findings ▪ Likely arises from pedunculated subserosal
• Grayscale ultrasound myomas that have completely separated from
uterus
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Uterus PARASITIC LEIOMYOMA
– Acquired blood supply from another source, • Because differential diagnosis includes malignancy,
such as omental or mesenteric vessels tissue sampling is usually required to confirm benign
▪ Alternative pathogenetic mechanism is that these parasitic leiomyoma
lesions may develop from peritoneal metaplasia o Treatment options once benign tissue is confirmed
o Iatrogenic origin ▪ Medical management (analgesia, hormone
▪ Develops after laparoscopic myomectomy or manipulation)
hysterectomy with use of electric tissue morcellator ▪ Surgical management (myomectomy)
– Electric tissue morcellator divides target lesions
into small fragments and removes them through
a tiny incision made in abdominal wall
– It is possible that these fragments may implant Consider
themselves in abdominopelvic cavity and
subsequently develop into a large fibroid
• Since lesion is separate from uterus, it is easily mistaken
for an adnexal mass
Gross Pathologic & Surgical Features • Identification of lesion as separate from both uterus
• Identical to typical uterine leiomyomas and ovaries is key to excluding adnexal mass
• If uterus, ovaries, and lesion are contiguous, primary
• Spherical, firm, white, and elastic in consistency source of lesion can be difficult to identify
Microscopic Features o Search for vascular supply of lesion
• Identical to typical uterine leiomyomas ▪ If uterine, likely parasitic leiomyoma on stalk
o If blood supply is completely neovascular with no
• Uniform, anastomosed, and whorled smooth muscle stalk, source of lesion remains unknown
cells
• Variable amounts of fibrous connective tissue Image Interpretation Pearls
• Small, infrequent blood vessels • Locate lesion separate from uterus and ovaries
• No significant mitosis, atypia, or necrosis • Pedicle may not be visible, especially on sonography
CLINICAL ISSUES SELECTED REFERENCES
Presentation 1. Deshmukh SP et al: Role of MR imaging of uterine
• Most common signs/symptoms leiomyomas before and after embolization. Radiographics.
32(6):E251-81, 2012
o Pelvic pain
2. Shanbhogue AK et al: Uncommon primary pelvic
▪ Pressure on adjacent organs (e.g., urethra, bladder retroperitoneal masses in adults: a pattern-based imaging
neck, ureter, rectum) approach. Radiographics. 32(3):795-817, 2012
• Other signs/symptoms 3. Cucinella G et al: Parasitic myomas after laparoscopic
o Can be associated with pseudo-Meigs syndrome surgery: an emerging complication in the use of
▪ Pseudo-Meigs syndrome consists of pleural morcellator? Description of four cases. Fertil Steril.
96(2):e90-6, 2011
effusion, ascites, and benign pelvic tumors (other
4. Hwang JH et al: An unusual presentation of a severely
than ovarian fibromas) calcified parasitic leiomyoma in a postmenopausal woman.
o Small/large bowel obstruction JSLS. 14(2):299-302, 2010
5. Fasih N et al: Leiomyomas beyond the uterus: unusual
Demographics
• Age
locations, rare manifestations. Radiographics.
28(7):1931-48, 2008
o Premenopausal women 6. Cohen DT et al: Uterine smooth-muscle tumors with
▪ Usually develops in premenopausal women, unusual growth patterns: imaging with pathologic
but may become clinically evident in pre- or correlation. AJR Am J Roentgenol. 188(1):246-55, 2007
postmenopausal patients 7. Muffly T et al: Massive leiomyoma of the broad ligament.
o May be hormone responsive Obstet Gynecol. 109(2 Pt2):563-5, 2007
▪ Can shrink with menopause 8. Pelage JP et al: Uterine fibroid vascularization and clinical
•
relevance to uterine fibroid embolization. Radiographics. 25
Epidemiology Suppl 1:S99-117, 2005
o Incidence of parasitic leiomyomas has not been 9. Murase E et al: Uterine leiomyomas: histopathologic
reported features, MR imaging findings, differential diagnosis, and
o Prevalence of iatrogenic parasitic leiomyoma ranges treatment. Radiographics. 19(5):1179-97, 1999
from 0.12-0.9% after morcellation procedures 10. Ueda H et al: Unusual appearances of uterine leiomyomas:
MR imaging findings and their histopathologic
Natural History & Prognosis backgrounds. Radiographics. 19 Spec No:S131-45, 1999
• May be asymptomatic depending on size and 11. Yeh HC et al: Parasitic and pedunculated leiomyomas:
ultrasonographic features. J Ultrasound Med. 18(11):789-94,
menstrual status
o Lesions are hormonally responsive and may enlarge 1999
to cause mass effect on nearby structures
• Torsion may occur
Treatment
• Often, surgical removal is required for symptomatic
relief or to alleviate impingement on nearby structures
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PARASITIC LEIOMYOMA
Uterus
year-old woman who underwent
laparoscopic hysterectomy and
bilateral salpingo-oophorectomy
5 years prior and was recently
diagnosed with early-stage colon
cancer shows a right pelvic mass
. The mass is predominantly
solid and hyperintense relative
to pelvic skeletal muscles, with
areas of very high signal intensity
representing cystic changes.
(Right) Sagittal T2WI MR in the
same patient shows a pelvic mass
just superior to and separate
from the vaginal cuff .

known uterine leiomyomas
who previously underwent
laparoscopic myomectomy
shows a right pelvic mass
demonstrating homogeneous
low signal intensity. There are
tubular signal void structures
supplying the mass and arising
from the mesentery. (Right) Axial
T1WI C+ FS MR in the same
patient shows heterogeneous
enhancement of the pelvic mass
and small signal void vascular
structures on the left side of
the mass.

old woman with a history
of hysterectomy for uterine
leiomyomas and who presented
with abdominal pain and
vomiting shows dilated loops of
small bowel . (Right) Coronal
MIP CECT in the same patient
shows small bowel dilatation and
a pelvic mass . There was a
transition point just posterior to
the mass. Surgery revealed small
bowel obstruction caused by a
torsion of a parasitic leiomyoma.
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Uterus BENIGN METASTASIZING LEIOMYOMA
Key Facts
Terminology • MR: Signal intensity similar to uterine leiomyomas
• Asymptomatic extrauterine benign leiomyomas Top Differential Diagnoses
Imaging • Metastatic leiomyosarcoma
• Incidental multiple well-circumscribed pulmonary • Other causes of multiple pulmonary nodules
nodules in an otherwise healthy woman o Metastases from other primary cancers
• Lung is most common site o Infectious or inflammatory disease
• Other sites include lymph nodes, peritoneum, and o Collagen-vascular disease
retroperitoneum Pathology
• Range from few mm to cm in diameter • Hematogenous metastases from benign uterine
• Less common presentations leiomyomas
o Miliary pattern
o Pedunculated pulmonary mass with large cyst Clinical Issues
o Giant cyst with multiple pulmonary nodules • Rare
• Can be associated with pneumothorax • Usually asymptomatic
• No associated calcifications, pleural effusion, or • Cough, chest pain, and dyspnea
mediastinal lymphadenopathy • Prognosis is usually excellent
• Homogeneous mild enhancement
(Left) Posteroanterior chest

radiograph in a 52-year-old
woman who underwent a
hysterectomy for uterine
leiomyomas 15 years prior
shows numerous bilateral,
well-defined pulmonary
nodules of variable size.
(Right) Axial CECT (lung
window) in the same patient
shows numerous bilateral,
well-defined, solid pulmonary
nodules of variable size.

patient shows numerous
bilateral, well-defined, solid
pulmonary nodules. The
nodules are homogeneous
and demonstrate soft tissue
attenuation with mild
enhancement. (Right) Axial
shows multiple soft tissue
pelvic masses . Biopsy of
both the pelvic masses and
pulmonary nodules showed
benign smooth muscle similar
to leiomyoma.
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BENIGN METASTASIZING LEIOMYOMA
Uterus
TERMINOLOGY • Circumscribed large lesions without encapsulation
• Some can be cystic, multiloculated
Definitions
• Asymptomatic extrauterine benign leiomyomas Microscopic Features
• Proliferation of smooth muscle cells with varying
amounts of intervening collagen
IMAGING • Well differentiated, benign appearing
General Features • No anaplasia or vascular invasion
• Best diagnostic clue • Rare mitotic figures
o Incidental well-circumscribed pulmonary nodules in • Immunohistochemistry: Strong reactivity for desmin
and muscle-specific actin
• Estrogen and progesterone receptors
an otherwise healthy woman
• Location
o Lung is most common site
o Other sites include lymph nodes, peritoneum, and CLINICAL ISSUES
retroperitoneum
• Size Presentation
o Range in diameter from a few mm to cm • Most common signs/symptoms
• Morphology o Usually asymptomatic
o Multiple bilateral well-defined pulmonary nodules • Other signs/symptoms
o Less common presentations o Cough, chest pain, and dyspnea have been described
▪ Miliary pattern o Little correlation between disease extent and
▪ Pedunculated pulmonary mass with large cyst pulmonary symptoms
▪ Giant cyst with multiple pulmonary nodules o Abdominal pain if peritoneal or retroperitoneal
o Can be associated with pneumothorax structures are affected
o No associated calcifications, pleural effusion, or
Demographics
mediastinal lymphadenopathy
o Homogeneous mild enhancement • Age
o Large range from premenopausal to postmenopausal
MR Findings women
• Signal intensity similar to that of uterine leiomyomas • Epidemiology
o Rare, ~ 200 reported cases in literature
DIFFERENTIAL DIAGNOSIS Natural History & Prognosis

Metastatic Leiomyosarcoma • Indolent: Majority of affected women die from other
causes
• Primary tumor: Uterine leiomyosarcoma • Prognosis is usually excellent
• Metastases with cytologic atypia and increased mitoses • Prognosis can depend on patient's estrogen status
mimicking primary tumor o Indolent in postmenopausal women
Other Causes of Multiple Pulmonary Nodules o In premenopausal women, reports of disease
• Metastases from other primary cancers progression, even leading to death
• Infectious or inflammatory disease Treatment
• Collagen-vascular disease • No standard treatment
• Therapy is not always indicated; may regress without
PATHOLOGY therapy (e.g., with menopause)
• Detection of estrogen and progesterone receptors in
General Features biopsy specimens can help optimize therapy
• Etiology • Hormonal manipulation: Progesterone or luteinizing
o Hematogenous metastases from benign uterine hormone-releasing hormone analogues
leiomyomas • Hysterectomy and oophorectomy
o Usually affects women after hysterectomy for
leiomyomas
▪ Extension from uterus into pelvic venous channels
SELECTED REFERENCES
▪ Tumors gain venous access from surgical trauma 1. Chen S et al: Pulmonary benign metastasizing leiomyoma
during hysterectomy from uterine leiomyoma. World J Surg Oncol. 11:163, 2013
o Nodules can be seen 3 months to 20 years after 2. Wei H et al: Benign pelvic metastatic leiomyoma: case
report. Clin Exp Obstet Gynecol. 40(1):165-7, 2013
hysterectomy
•
3. Fasih N et al: Leiomyomas beyond the uterus: unusual
Associated abnormalities locations, rare manifestations. Radiographics.
o Diffuse peritoneal leiomyomatosis 28(7):1931-48, 2008
o Intravenous leiomyomatosis 4. Abramson S et al: Benign metastasizing leiomyoma: clinical,
o Diffuse uterine leiomyomatosis imaging, and pathologic correlation. AJR Am J Roentgenol.
176(6):1409-13, 2001
• Solid, white-tan homogeneous nodules
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Uterus DIFFUSE LEIOMYOMATOSIS
Key Facts
Terminology • Uterine sarcoma
• Unusual growth pattern of uterine smooth muscle Pathology
proliferation resulting in diffuse enlargement of uterus
• Nodules are composed of uniform, spindled, smooth
Imaging muscle cells
• Innumerable ill-defined leiomyomas resulting in Clinical Issues
diffusely enlarged, lobulated uterus
• Poorly defined nodules, without discrete margins • Benign entity but can be complicated with
• MR is method of choice, showing ill-defined
hemorrhage and rupture
leiomyomas with intermediate signal intensity that
• Hysterectomy is treatment of choice because of diffuse
nature of disease
diffusely enhances
o MR useful to confirm bridging soft tissue from • Alternatively, uterine artery embolization may be
performed to control symptoms and reduce uterine
uterine myometrium
•
volume
Ultrasound can show enlarged uterus with
heterogeneous echogenicity and multiple nodules
• In young women who prefer to preserve uterine
function and fertility, conservative treatment may be
Top Differential Diagnoses offered
• Disseminated peritoneal leiomyomatosis • Menorrhagia &/or dysmenorrhea
• Intravenous leiomyomatosis

in a 42-year-old woman
with diffuse leiomyomatosis
shows an enlarged uterus
replaced by leiomyomata
containing regions of hyaline
degeneration . Note the
diffuse replacement of the
uterus. (Right) Coronal T2WI
MR in a patient with diffuse
leiomyomatosis shows a
whorled appearance of the
uterus . The uterus is
replaced by leiomyomata
rather than having distinct
well-defined masses.
Regions of liquefaction
correlate with hyaline myxoid
degeneration.
(Left) Sagittal T1WI C+

FS MR in a 48-year-old
woman demonstrates a large
heterogeneous mass arising
from a uterus with soft tissue
components . Surgical
pathology revealed diffuse
leiomyomatosis. (Right) Axial
CECT in a woman with diffuse
leiomyomatosis shows a large
soft tissue mass arising
from the pelvis, filling in
the entire abdominal cavity.
Surgical resection proved to
be diffuse smooth muscle
leiomyomatosis.
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DIFFUSE LEIOMYOMATOSIS
Uterus
TERMINOLOGY Microscopic Features
Definitions
• Nodules are composed of uniform, spindled, smooth
muscle cells
• Unusual growth pattern of uterine smooth muscle
proliferation resulting in diffuse enlargement of uterus
CLINICAL ISSUES
IMAGING Presentation
General Features
o Menorrhagia &/or dysmenorrhea
• Best diagnostic clue o Abdominal pain &/or pressure
o Diffuse enlargement of uterus replaced with o Infertility
innumerable ill-defined fibroids
• Location Demographics
o Myometrium is diffusely involved • Age
• Size o Usually younger women
o Smooth muscle nodules range from microscopic to Natural History & Prognosis
sizable • Benign
• Morphology
• Complications such as hemorrhage or uterine rupture
o Uterus is often diffusely enlarged and lobulated are reported
Imaging Recommendations Treatment
• Best imaging tool • Hysterectomy is treatment of choice because of diffuse
o MR is method of choice nature of disease
Ultrasonographic Findings • Alternatively, uterine artery embolization may be
• Grayscale ultrasound performed to control symptoms and reduce uterine
volume
o Multiple leiomyomas and enlarged uterus with
heterogeneous echogenicity
• In young women who prefer to preserve uterine
function and fertility, conservative treatment may be
CT Findings offered
• CECT o Extensive myomectomy with sparing sufficient
o Multiple enhancing leiomyomas (nodules) resulting myometrial tissue for uterine reconstruction
in diffuse enlargement of uterus
MR Findings SELECTED REFERENCES
• T1WI 1. Thiry T et al: Diffuse abdominopelvic leiomyomatosis:
o Nodules are isointense to muscle CT and MR imaging findings with histopathological
• T2WI correlation. Diagn Interv Imaging. 95(1):105-8, 2014
2. Keskin G et al: Diffuse peritoneal leiomyomatosis. J Obstet
o Nodules are ill-defined and have intermediate signal
Gynaecol. 33(5):535-6, 2013
intensity 3. Agarwal K et al: Diffuse leiomyomatosis of the uterus
• T1WI C+ diagnosed during pregnancy with successful vaginal
o Diffuse and marked enhancement of nodules delivery. Indian J Pathol Microbiol. 55(4):585-6, 2012
4. Koh J et al: Uterine artery embolization (UAE) for diffuse
leiomyomatosis of the uterus: clinical and imaging results.
DIFFERENTIAL DIAGNOSIS Eur J Radiol. 81(10):2726-9, 2012
5. Pai D et al: Diffuse uterine leiomyomatosis in a child. Pediatr
Disseminated Peritoneal Leiomyomatosis Radiol. 42(1):124-8, 2012
• Multiple smooth muscle nodules involving uterus with 6. Purohit R et al: A case of diffuse uterine leiomyomatosis who
had two successful pregnancies after medical management.
dissemination in peritoneal cavity
Fertil Steril. 95(7):2434, 2011
Intravenous Leiomyomatosis 7. Ip PP et al: Uterine smooth muscle tumors other than
• Enlarged uterus with masses extending into the ordinary leiomyomas and leiomyosarcomas: a review
of selected variants with emphasis on recent advances
extrauterine veins, inferior vena cava (IVC), and heart
and unusual morphology that may cause concern for
Uterine Sarcoma malignancy. Adv Anat Pathol. 17(2):91-112, 2010
• More aggressive, heterogeneous mass, which may have 8. Coskun A et al: A case with diffuse uterine leiomyomatosis
and review of the literature. Clin Exp Obstet Gynecol.
evidence of metastasis at presentation
35(3):227-30, 2008
9. Scheurig C et al: Uterine artery embolization in patients
PATHOLOGY with symptomatic diffuse leiomyomatosis of the uterus. J
Vasc Interv Radiol. 19(2 Pt 1):279-84, 2008
Gross Pathologic & Surgical Features 10. Cohen DT et al: Uterine smooth-muscle tumors with
• Innumerable nodules (leiomyomas) that are less unusual growth patterns: imaging with pathologic
correlation. AJR Am J Roentgenol. 188(1):246-55, 2007
circumscribed than leiomyomata
11. Thomas EO et al: Diffuse uterine leiomyomatosis with
uterine rupture and benign metastatic lesions of the bone.
Obstet Gynecol. 109:528-30, 2007
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Uterus DIFFUSE LEIOMYOMATOSIS
(Left) Coronal T2WI FSE MR

shows diffuse enlargement
of the uterus replaced by
relative T2 dark leiomyomas
that are poorly defined.
Note the regions of T2 bright
degeneration and poorly
defined margins . (Right)
patient shows the extent of the
enlarged diffusely replaced
leiomyomatous uterus. Note
the poorly defined margins of
the leiomyomas .
(Left) Coronal T1WI C+

FS MR of a 56-year-old
woman with a diffusely
enlarged leiomyomatous
uterus shows that there are
no defined margins of the
heterogeneously enhancing
fibroids , some of which
demonstrate regions of hyaline
degeneration . (Right) Axial
CECT shows a woman with
a markedly enlarged uterus
replaced by poorly defined
leiomyomas , some of
which have undergone myxoid
degeneration . Surgical
resection confirmed diffuse
leiomyomatosis.

demonstrates an enlarged
uterus replaced by T2 dark
fibroids with hyperintense
regions of degeneration.
Surgical pathology confirmed
diffuse leiomyomatosis. (Right)
Sagittal T2WI FSE MR in the
same patient better defines the
extent of the enlarged uterus
replaced by leiomyomas .
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DIFFUSE LEIOMYOMATOSIS
Uterus
woman shows a large, ill-defined
soft tissue mass replacing
the abdominal cavity. Surgical
pathology confirmed diffuse
benign leiomyomatosis. (Right)
Axial T1WI C+ FS MR shows an
enlarged leiomyomatous uterus
replaced with enhancing nodules
and regions of degeneration
. Surgical resection confirmed
diffuse leiomyomatosis.
(Left) Coronal T1WI C+ FS

the extent of the enlarged
leiomyomatous uterus. Note
the ill-defined margins of
the leiomyomas replacing the
uterus. (Right) Coronal T1WI
C+ FS MR in a woman who
presented with abdominal
mass shows an enlarged uterus
replaced by diffusely enhancing
soft tissue . The correlating
smooth muscle proliferation in
this patient confirmed diffuse
leiomyomatosis.

some regions of degeneration
. (Right) Axial T2WI FS MR
shows an enlarged lobulated
uterus replaced by isointense
masses . Surgical pathology
confirmed benign smooth muscle
leiomyomata.
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Uterus INTRAVENOUS LEIOMYOMATOSIS
Key Facts
Terminology • Benign metastasizing leiomyomatosis
• Rare form of benign uterine myomas that directly • Renal cell carcinoma invading IVC
invade into adjacent pelvic veins • Ovarian vein thrombosis
Imaging Pathology
• 80% of tumors extend from uterus into extrauterine • Unclear; tumor may arise from uterine leiomyoma,
pelvic veins walls of uterine vessel, or myometrium
• Heterogeneous, avidly enhancing myoma in uterus Clinical Issues
o Enhancing tumor may extend to iliac, uterine or
gonadal veins, inferior vena cava (IVC), heart and • Right-sided congestive symptoms: Lower limb
swelling, dyspnea, congestive heart failure, ascites
• Total abdominal hysterectomy, bilateral salpingo-
pulmonary arteries
• Low signal voids on MR
• Coronal plane demonstrates extent of disease
oophorectomy, and excision of extrauterine tumor
• May necessitate sternotomy (using cardiopulmonary
Top Differential Diagnoses bypass or circulatory arrest) as well as laparotomy in a
• Leiomyosarcoma
•
single or 2-stage operation
• Diffuse leiomyomatosis
•
Long-term prognosis very good after resection
• Disseminated leiomyomatosis
30% of patients may have persistent or continued
growth of incompletely excised intravenous tumor
(Left) Axial CECT centered

at the heart shows a large
intracardiac mass centered
in the right atrium and
extending into the right
ventricle which confirmed
intracardiac leiomyomatosis.
(Right) Axial CECT lower down
the low-attenuation mass
expanding in the infrahepatic
inferior vena cava . Note
the heterogeneous mottled
enhancement of the liver due
to the caval tumor resulting
in outflow obstruction.

in the pelvis in the same
patient shows an enlarged
uterus with soft tissue
replacing the myometrium ,
resulting in obliteration of the
endometrial cavity. Surgical
pathology confirmed a diffuse
leiomyomatous uterus. (Right)
Axial CECT in the lower pelvis
in the same patient shows the
extent of the leiomyomatous
tumor with extension
to the pelvic side wall and
involvement of the pelvic
veins which confirmed
intravenous extension of
uterine leiomyomatosis.
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INTRAVENOUS LEIOMYOMATOSIS
Uterus
TERMINOLOGY Echocardiographic Findings
Abbreviations
• Echocardiogram
o Elongated, mobile masses extending from lower body
• Intravenous leiomyomatosis (IVL) veins including IVC and azygos vein
o Intravenous tumor has multiple venous or cardiac
Definitions
• Rare form of benign uterine myomas that directly attachments
o Tumor fills veins, right heart chambers, and, rarely,
invade into adjacent pelvic veins and may extend to
pulmonary arteries
inferior vena cava (IVC) and right atrium o Valvular disease such as tricuspid regurgitation
IMAGING Angiographic Findings

• Inferior vena cavogram
General Features o Demonstrates IVC occlusion with multiple
• Best diagnostic clue intravascular filling defects and collateral circulation
o Enlarged leiomyomatous uterus that invades and
extends into adjacent pelvic veins, IVC, and right
atrium • Best imaging tool
o Contrast-enhanced MR or CT
• Location
• Protocol advice
o 80% of tumors extend from uterus into extrauterine
o Coronal plane demonstrates extent of disease
pelvic veins
o Cardiac involvement determines surgical approach
▪ Majority of cases involve 1 side of venous system,
uterine vein more common than ovarian vein
▪ 40% extend into IVC and right atrium DIFFERENTIAL DIAGNOSIS
▪ Cardiac involvement in up to 10% of cases
Leiomyosarcoma
CT Findings • No grossly visible vascular involvement
• CECT
o Enlarged uterus with heterogeneously enhancing Diffuse Leiomyomatosis
uterus replaced by myomas with variable intravenous • Replacement of myometrium by multiple, confluent,
growth into myometrial veins and pelvis benign leiomyomas
o Enhancing tumor may extend to iliac, uterine or
Disseminated Leiomyomatosis
gonadal veins, IVC, heart, and pulmonary arteries
o Ureters may be dilated (compression from pelvic • Multiple, benign leiomyomas in peritoneal cavity
tumor) Benign Metastasizing Leiomyomatosis
• CTA • Benign leiomyomas in solid organs, most common in
o Defines extravascular, intravascular, and intracardiac lung or liver
extension of tumor
▪ Involved vessels are enlarged and distended with Renal Cell Carcinoma Invading IVC
enhancing tumor • Rarely have endocardial attachments
– Collateral vessels may develop • Mass-like appearance, not long mobile structures,
▪ Direct extension may involve pulmonary arteries extension to IVC from renal veins
and branches; tumor embolism is rarely reported Right-Sided Heart Thrombus in Transit
MR Findings • Elongated mobile masses without multiple points of
• T2WI attachment in heart chambers
o Low signal intensity uterine myoma with serpentine • No flow on color Doppler, no enhancement
tubular projections that involve myometrium Ovarian Vein Thrombosis
o Prominent tubular signal voids
• • Occurs in febrile, postpartum patient with pain
T1WI C+
o Heterogeneous, avidly enhancing uterine myoma • No enhancement of thrombus
o Intravenous growth to veins of uterus and pelvic
ligaments PATHOLOGY
o Can extend into IVC and heart
General Features
Ultrasonographic Findings • Etiology
• Grayscale ultrasound o Unclear; tumor may arise from uterine leiomyoma,
o Enlarged uterus with heterogeneous, hypoechoic walls of uterine vessel, or myometrium
leiomyoma
o Intravascular extension of tumor has multiple Gross Pathologic & Surgical Features
venous attachments within involved vessels • Enlarged uterus replaced by solitary or multiple mural
• Color Doppler or submucosal leiomyomas
o Masses are typically lobulated or multinodular
o Demonstrates flow around tumor and internal
(grape-like), rubbery, and have fluid accumulation
vascularity within intravascular tumor
o Tumor frequently extends to broad ligament or
parametrium
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Uterus INTRAVENOUS LEIOMYOMATOSIS
• Serpentine plugs of tumor within myometrial or SELECTED REFERENCES

cervical veins
1. Sogabe M et al: Uterine intravenous leiomyomatosis with
Microscopic Features right ventricular extension. Ann Thorac Cardiovasc Surg.
• Endothelium-covered proliferations of benign smooth 2.
Epub ahead of print, 2014
Osawa H et al: A case of intravenous leiomyomatosis of
muscle within lumen of myometrial vessels
o Most vessels are veins, some lymphatics uterine origin, extending through the inferior vena cava to
o Intravascular tumor can be unattached or have right atrium. Gen Thorac Cardiovasc Surg. 61(2):104-7, 2013
3. Ribeiro V et al: Intracardiac leiomyomatosis complicated by
delicate to broad-based intimal attachments
•
pulmonary embolism: a multimodality imaging case of a
In typical cases, intravascular tumor closely resembles rare entity. Can J Cardiol. 29(12):1743, 2013
uterine leiomyoma 4. Wei H et al: Benign pelvic metastatic leiomyoma: case
o May have zones of hyalinization report. Clin Exp Obstet Gynecol. 40(1):165-7, 2013
• Neoplastic cells have minimal nuclear atypia and low 5. Xu ZF et al: Uterine intravenous leiomyomatosis with
cardiac extension: Imaging characteristics and literature
mitotic index
o Variants should be distinguished from endometrial review. World J Clin Oncol. 4(1):25-8, 2013
6. Kang LQ et al: Diagnosis of intravenous leiomyomatosis
stromal sarcoma and leiomyosarcoma
extending to heart with emphasis on magnetic resonance
imaging. Chin Med J (Engl). 125(1):33-7, 2012
CLINICAL ISSUES 7. Low G et al: Case 188: Intravenous leiomyomatosis with
intracaval and intracardiac involvement. Radiology.
Presentation 265(3):971-5, 2012
• Most common signs/symptoms 8. Peng HJ et al: Intravenous leiomyomatosis: CT findings.
Abdom Imaging. 37(4):628-31, 2012
o Pelvic or lower abdominal mass from enlarged uterus
9. Barksdale J et al: Intravenous leiomyomatosis presenting as
o Abnormal uterine bleeding, pain acute Budd-Chiari syndrome. J Vasc Surg. 54(3):860-3, 2011
• Other signs/symptoms 10. Du J et al: Intravenous leiomyomatosis of the uterus: a
o Uterine prolapse, stress incontinence clinicopathologic study of 18 cases, with emphasis on early
o Right-sided congestive symptoms: Lower limb diagnosis and appropriate treatment strategies. Hum Pathol.
42(9):1240-6, 2011
swelling, dyspnea, congestive heart failure, ascites
o Syncope (from obstruction at tricuspid valve) 11. Elbaqqali L et al: [Intravascular leiomyomatosis of the
uterus.] Tunis Med. 89(12):941-3, 2011
o Systemic embolism, sudden death
12. Guo X et al: Echocardiographic characteristics of
Demographics intravenous leiomyomatosis with intracardiac extension:
• Age a single-institution experience. Echocardiography.

28(9):934-40, 2011
o Usually premenopausal 13. Galajda Z et al: The diagnosis, morphological particularities,
• Epidemiology and surgical technique in a case of intravascular leiomyoma
o Underdiagnosed since it is easily missed in early extended to the right heart chambers. J Vasc Surg.
stages 51(4):1000-2, 2010
14. Sun C et al: Intravenous leiomyomatosis: diagnosis and
Natural History & Prognosis follow-up with multislice computed tomography. Am J Surg.
• Long-term prognosis is very good after resection 200(3):e41-3, 2010
• 30% of patients may have persistent or continued 15. Cano Alonso R et al: Role of multidetector CT in the
management of acute female pelvic disease. Emerg Radiol.
growth of incompletely excised intravenous tumor 16(6):453-72, 2009
Treatment 16. Dalainas I: Vascular smooth muscle tumors: review of the
• Options, risks, complications 17.

literature. Int J Surg. 6(2):157-63, 2008
Arif S et al: Intravascular leiomyomatosis and benign
o Total abdominal hysterectomy, bilateral salpingo- metastasizing leiomyoma: an unusual case. Int J Gynecol
oophorectomy, and excision of extrauterine tumor Cancer. 16(3):1448-50, 2006
o May necessitate sternotomy (using cardiopulmonary 18. Wong YY et al: Intravenous leiomyomatosis: computed
bypass) as well as laparotomy in a single or 2-stage tomography diagnosis. Hong Kong Med J. 12(3):239-40,
operation 2006
o Tamoxifen can be used to help control growth of 19. Moorjani N et al: Intravenous uterine leiomyosarcomatosis
with intracardial extension. J Card Surg. 20(4):382-5, 2005
unresectable tumor 20. Lam PM et al: Intravenous leiomyomatosis: two cases with
different routes of tumor extension. J Vasc Surg. 39(2):465-9,
DIAGNOSTIC CHECKLIST 2004
21. Diakomanolis E et al: Intravenous leiomyomatosis. Arch
Consider Gynecol Obstet. 267(4):256-7, 2003
• Preoperative imaging delineates extent of tumor but 22. Bodner K et al: Intravenous leiomyomatosis of the uterus.
Anticancer Res. 22(3):1881-3, 2002
does not differentiate between benign and malignant
etiologies
• CT and MR are ideal techniques to demonstrate full
extent of tumor from pelvis to thorax
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Uterus
(Left) Axial T2WI FS MR
through the pelvis shows several
pedunculated fibroids
extending laterally to the pelvic
veins along the right pelvic side
wall and right common iliac
vein . (Right) Axial CECT in
the same patient shows a large,
heterogeneous leiomyomatous
uterus with extension into the
right pelvic side wall and pelvic
veins .

a palpable right inguinal mass
shows multiple uterine masses
, some showing nodular
calcifications . There is also
a calcified right inguinal mass
centered on the right femoral
vein. A tubular soft tissue density
structure within the right adnexa
represents tumor extension
into the uterine vein. (Right)
Axial CECT in the same patient
shows masses within the right
uterine vein and femoral vein
.

patient shows tumors in the right
uterine and external iliac
veins. (Right) Coronal CECT in
the same patient shows a tumor
within the right uterine vein. The
intravenous leiomyoma extended
from the uterus into the uterine
vein, internal iliac vein , and
then into the external iliac vein
to present within the femoral
vein as an inguinal mass.
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Uterus DISSEMINATED PERITONEAL LEIOMYOMATOSIS
Key Facts
Terminology • Benign metastasizing leiomyomas
• Rare benign condition of smooth muscle tumors • Intravenous leiomyomatosis
disseminated along subperitoneal surfaces
Pathology
Imaging • Grossly invasive but histologically benign
• Solid and complex soft tissue masses in peritoneum, • Subperitoneal smooth muscle proliferation with little
uterus, broad ligaments, ovaries, mesentery, intestines, mitotic activity, absent cell atypia and tumor necrosis
omentum
• Heterogeneous enhancement, similar to uterine Clinical Issues
fibroids or myometrium • Reproductive age, rare in postmenopausal women
• Not associated with infiltration of omentum, ascites, • Benign course; recurrence has been reported
or liver metastases • Spontaneous regression when ↓ exposure to estrogen
• Peritoneal nodules do not show increased uptake • Conservative, GnRH agonists or bilateral salpingo-
of FDG-18 as would be seen in leiomyosarcoma or oophorectomy ± hysterectomy
peritoneal carcinomatosis • Pelvic pain, uterine bleeding, urinary frequency,
peritonitis, asymptomatic
Top Differential Diagnoses
• Metastatic malignant neoplasm; leiomyosarcoma Diagnostic Checklist
• Multiple pedunculated uterine leiomyomas • Mimics peritoneal carcinomatosis

old woman with peritoneal
leiomyomatosis demonstrates
well-defined soft tissue masses
in the peritoneal cavity. Note
the leiomyoma in the left mid
abdomen . (Right) Axial
shows soft tissue leiomyomata
in the right and left mid
abdomen.

patient shows large peritoneal
soft tissue leiomyoma lower
down in the right lower
quadrant . (Right) Axial
shows large leiomyomata
arising from the pelvis
. Surgical resection
confirmed diffuse peritoneal
leiomyomatosis.
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DISSEMINATED PERITONEAL LEIOMYOMATOSIS
Uterus
o Endometrial hyperplasia, leiomyomas, endometriosis
TERMINOLOGY
Definitions Gross Pathologic & Surgical Features
• Rare benign condition of smooth muscle tumors • Grossly invasive but histologically benign
disseminated along subperitoneal surfaces Microscopic Features
• Subperitoneal smooth muscle proliferation with little
IMAGING mitotic activity, absent cell atypia and tumor necrosis
o Cells arranged in interdigitating fascicles
General Features • Nodules may contain fibroblasts, myofibroblasts, and
• Size decidual and endometrial stromal cells
o Few millimeters to several centimeters
CT Findings CLINICAL ISSUES

• CECT
Presentation
o Solid and complex soft tissue masses in peritoneum,
uterus, broad ligaments, ovaries, mesentery,
o Pelvic pain, uterine bleeding, urinary frequency,
intestines, omentum
o Enhancement similar to uterus or other fibroids peritonitis, or asymptomatic
o Not associated with infiltration of omentum, ascites, Demographics
or liver metastases • Age
o Reproductive, rare in postmenopausal women
MR Findings
• T1WI • Gender
o Masses similar in signal intensity to uterine o Female; reportedly only 1 case in a male
myometrium • Epidemiology
• T2WI o Rare, over 100 cases reported in total
o Low signal intensity due to smooth muscle Natural History & Prognosis
• T1WI C+ • Benign course; recurrence has been reported
o Variable enhancement
• Spontaneous regression when ↓ exposure to estrogen
Ultrasonographic Findings Treatment
• Solid echogenic soft tissue peritoneal masses similar to • Conservative, gonadotropin-releasing hormone
uterine myometrium agonists
Nuclear Medicine Findings • Bilateral salpingo-oophorectomy ± hysterectomy
• PET
o Peritoneal nodules do not show increased uptake DIAGNOSTIC CHECKLIST
of FDG-18, which would differentiate from
leiomyosarcoma or peritoneal carcinomatosis Consider
• Mimics peritoneal carcinomatosis
SELECTED REFERENCES
Metastatic Malignant Neoplasm
• Nodules on peritoneal surface demonstrate avid uptake 1. Thiry T et al: Diffuse abdominopelvic leiomyomatosis:
CT and MR imaging findings with histopathological
on FDG PET/CT
correlation. Diagn Interv Imaging. 95(1):105-8, 2014
Leiomyosarcoma 2. Keskin G et al: Diffuse peritoneal leiomyomatosis. J Obstet
• Higher mitotic index, nuclear atypia, tumor necrosis, 3.
Gynaecol. 33(5):535-6, 2013
Onorati M et al: Leiomyomatosis peritonealis disseminata:
and infiltrative growth into adjacent structures
pregnancy, contraception and myomectomy of its
Multiple Pedunculated Uterine Leiomyomas pathogenesis. Pathologica. 105(3):107-9, 2013
• Look for attachment of leiomyomas to uterus 4. Mueller F et al: Disseminated peritoneal leiomyomatosis
with endometriosis. J Minim Invasive Gynecol. 19(3):380-2,
Intravenous Leiomyomatosis 2012
• Extension of uterine leiomyoma into venous channels 5. Du J et al: Intravenous leiomyomatosis of the uterus: a
clinicopathologic study of 18 cases, with emphasis on early
diagnosis and appropriate treatment strategies. Hum Pathol.
42(9):1240-6, 2011
PATHOLOGY 6. Lamarca M et al: Leiomyomatosis peritonealis disseminata
General Features with malignant degeneration. A case report. Eur J Gynaecol
• Etiology 7.
Oncol. 32(6):702-4, 2011
Park BJ et al: Disseminated peritoneal leiomyomatosis after
o Smooth muscle metaplasia of subperitoneal hysterectomy: a case report. J Reprod Med. 56(9-10):456-60,
pluripotent mesenchymal stem cells 2011
o Many cases associated with pregnancy, granulosa cell 8. Rosica G et al: A case of disseminated peritoneal
tumor, or oral contraceptive use leiomyomatosis and diffuse uterine leiomyomatosis. Clin
• Associated abnormalities Exp Obstet Gynecol. 38(1):84-7, 2011
2
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Uterus LIPOMATOUS UTERINE TUMORS
Key Facts
Terminology o Areas of low signal due to presence of smooth muscle
o Chemical shift artifact on in- and opposed-phase
• Uterine tumors composed entirely, or in part, of imaging
adipose tissue, ± intermixed smooth muscle and
fibrous tissue • Hyperechoic well-defined mass on US
o Posterior attenuation, shadowing
Imaging
• Fat-containing mass of uterus Top Differential Diagnoses
• Uterine corpus (90%), less commonly cervix • Benign cystic ovarian teratoma
• Spherical or ovoid mass • Benign degenerated uterine leiomyoma
• Well circumscribed, encapsulated • Malignant mixed mesodermal tumor (MMMT)
• Heterogeneous contents • Sarcomatous degeneration of uterine leiomyoma
• Uterine origin confirmed by multiplanar reformats • Benign pelvic lipoma
and by bridging myometrium • Pelvic liposarcoma
• Typically discovered as incidental finding on Clinical Issues
• Most occur in postmenopausal women
ultrasound, CT
• MR
o High signal intensity foci, isointense with • Almost invariably benign
subcutaneous fat on T1WI • Rare reports of liposarcoma arising in lipoleiomyoma
(Left) Transverse view of the

uterus shows a large echogenic
mass that replaces
the uterine myometrium.
Pathology confirmed
lipoleiomyoma in this 62-
year-old woman. (Right)
Longitudinal ultrasound image
of the uterus demonstrates
a large echogenic mass with
posterior acoustic shadowing
corresponding to a large,
fat-containing uterine mass.
Surgical resection confirmed a
large lipoleiomyoma.
(Left) Axial CECT view of the

pelvis in a 72-year-old woman
with a lipoleiomyoma shows
a large, predominantly fat-
containing mass in the
uterine myometrium, with
soft tissue attenuation within
corresponding to smooth
muscle cells separated by
fibrous tissue . (Right)
Axial CECT image in a 56-
year-old woman shows a fat-
containing myometrial
mass with soft tissue strands
within corresponding to a
lipoleiomyoma.
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Uterus
TERMINOLOGY Ultrasonographic Findings
• Hyperechoic well-defined mass
Abbreviations • Hypoechoic internal foci, septations
• Lipomatous uterine tumors (LUT) • Posterior attenuation, shadowing
Definitions • May be partially surrounded by hypoechoic rind
• Uterine tumors composed entirely, or in part, of Imaging Recommendations
adipose tissue, ± intermixed smooth muscle and
fibrous tissue • Best imaging tool
o Typically discovered as incidental finding on
Subtypes ultrasound, CT
• Lipoleiomyoma (LLM), lipoma, fibromyolipoma (FML), o CT often diagnostic, especially for intramural
angiolipoleiomyoma (ALLM) lipomatous tumors
o MR modality of choice for diagnosis
▪ High sensitivity and specificity for presence of fat
IMAGING ▪ Most accurate modality to establish uterine origin
General Features in pedunculated masses
• Best diagnostic clue • Protocol advice
o Fat-containing mass of uterus o T1WI and T1WI FS must be obtained to confirm
• Location bright signal represents fat rather than hemorrhagic
o Uterine corpus (90%), less commonly cervix or high mucin content leiomyoma
o Intramural (60%), subserosal (35%), rarely
submucosal (5%) DIFFERENTIAL DIAGNOSIS
• Size
Benign Cystic Ovarian Teratoma
o Variable, mean: 5-10 cm
• Morphology • Most common fat-containing pelvic mass
o Spherical or ovoid mass • Extrauterine mass of ovarian origin
o Well circumscribed, encapsulated • Occurs mainly during reproductive years rather than
o Heterogeneous contents after menopause
o Uterine origin difficult to establish for pedunculated • Contains fat, calcium, fluid, and soft tissue
or exophytic lesions, especially on CT or ultrasound • Teeth, fat/fluid level, and dermoid plug are diagnostic
Radiographic Findings Benign Degenerated Uterine Leiomyoma
• Radiography • Red (hemorrhagic) degeneration
o Radiolucent pelvic mass partially surrounded by o Hyperintense signal T1WI and T1WI FS
radiodense rind o Often low signal T2WI
CT Findings • Increased risk for degeneration during pregnancy
• Fat density (range -120 to -20 HU) with variable areas of • Mucinous cystic degeneration
soft tissue density within uterus o Hyperintense signal T1WI and T1WI FS
o Bright signal T2WI
MR Findings
• T1WI Malignant Mixed Mesodermal Tumor (MMMT)
o High signal intensity foci, isointense to subcutaneous • Large, broad-based uterine mass with aggressive
myometrial invasion
• May show foci of signal loss on opposed-phase images
fat
o Areas of low signal due to presence of smooth muscle
o Chemical shift artifact on in- and opposed-phase due to small quantities of microscopic fat
imaging Nonteratomatous Lipomatous Ovarian Tumor
• T1WI FS • Ovarian rather than uterine origin
o Lipomatous areas become low signal intensity
• Extremely rare
(follows signal of subcutaneous fat)
o Hemorrhagic or mucinous cystic degenerated • Ovarian lipoma or lipoleiomyoma
leiomyoma will maintain high signal intensity Sarcomatous Degeneration of Uterine
• T2WI Leiomyoma
o Intermediate or high signal intensity, isointense to
• Inhomogeneous mass of myometrial origin
subcutaneous fat
o Chemical shift artifact clue to lipomatous contents of
• Cystic degeneration and necrosis, absence of fat
mass
• Hemorrhagic and hyaline degeneration, remain bright
•
on T1WI FS
T1WI C+ FS
o Smooth muscle component enhances slightly
• No definite imaging criteria allowing differentiation of
degenerated benign leiomyoma from leiomyosarcoma
o Capsule demonstrates moderate vascularity
• Lipomatous component is isointense to subcutaneous Benign Pelvic Lipoma
fat on all sequences • Extraperitoneal
• Uterine origin confirmed by multiplanar reformats and • Well circumscribed
by bridging myometrium • Homogeneous fat-containing mass 2
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Uterus LIPOMATOUS UTERINE TUMORS
• Distinct from uterus DIAGNOSTIC CHECKLIST

Pelvic Liposarcoma Consider
• Usually extraperitoneal rather than intraperitoneal • MR is most accurate modality to confirm uterine origin
• Heterogeneous soft tissue mass • MR is most sensitive and specific modality to confirm
• Variable amounts of fat presence of fat
PATHOLOGY • Establish uterine origin of mass
General Features • Presence of fat within uterus is virtually diagnostic of
• Etiology LUT
o Various theories suggested
▪ Originates from misplaced embryonal mesodermal SELECTED REFERENCES
rests with potential for lipoblastic differentiation 1. Chu CY et al: Diagnostic challenge of lipomatous uterine
▪ Pericapillary pluripotential mesenchymal cells tumors in three patients. World J Radiol. 4(2):58-62, 2012
▪ Lipoblasts migrating along uterine arteries and 2. Terada T: Giant subserosal lipoleiomyomas of the
nerves uterine cervix and corpus: a report of 2 cases. Appl
▪ Metaplasia of stromal or smooth muscle cells in Immunohistochem Mol Morphol. Epub ahead of print,
preexisting leiomyoma 2012
• Associated abnormalities 3.
4.
Ghosh B et al: Lipoleiomyoma. BMJ Case Rep. 2011
McDonald AG et al: Liposarcoma arising in uterine
o High prevalence of concomitant uterine leiomyoma
lipoleiomyoma: a report of 3 cases and review of the
Gross Pathologic & Surgical Features literature. Am J Surg Pathol. 35(2):221-7, 2011
• Well circumscribed, usually encapsulated 5. Terada T: Huge lipoleiomyoma of the uterine cervix. Arch
• Consistency varies with proportion of different

Gynecol Obstet. 283(5):1169-71, 2011
6. Vural C et al: Intravenous lipoleiomyomatosis of uterus
components with cardiac extension: a case report. Pathol Res Pract.
o Soft, pale yellow mass in rare cases of pure lipomas 207(2):131-4, 2011
o Firm gray-white mass with soft yellow areas (LLM) 7. Ding DC et al: Lipoleiomyoma of the uterus. Taiwan J Obstet
o Vascular patches, especially at periphery (ALLM) Gynecol. 49(1):94-6, 2010
8. Manjunatha HK et al: Lipoleiomyoma of uterus in a
Microscopic Features postmenopausal woman. J Midlife Health. 1(2):86-8, 2010
• Lipomatous and smooth muscle cell neoplasia in all 9. Sudhamani S et al: Lipoleiomyoma of uterus: a case report
with review of literature. Indian J Pathol Microbiol.
tumors (except pure lipoma)
• Usually leiomyomatous component is more abundant 10.
53(4):840-1, 2010
Mignogna C et al: A case of pure uterine lipoma:
than adipose tissue
• FML: Hyalinized fibrous stroma
immunohistochemical and ultrastructural focus. Arch
Gynecol Obstet. 2009 Dec;280(6):1071-4. Epub 2009 May
• ALLM: Marked proliferation of abnormal blood vessels 23. Erratum in: Arch Gynecol Obstet. 280(6):1075, 2009
11. Loffroy R et al: Lipoleiomyoma of the uterus: imaging
features. Gynecol Obstet Invest. 66(2):73-5, 2008
CLINICAL ISSUES 12. Erdem G et al: Pure uterine lipoma. Magn Reson Imaging.
25(8):1232-6, 2007
Presentation 13. Fernandes H et al: Pure lipoma of the uterus: a rare case
• Most common signs/symptoms report. Indian J Pathol Microbiol. 50(4):800-1, 2007
o Usually asymptomatic 14. Kashyap S et al: A rare spectrum of lesions encountered in
o If symptomatic, symptoms parallel uterine fibroid uterus: histopathological report. Indian J Pathol
Microbiol. 50(4):790-1, 2007
leiomyomas
15. Kitajima K et al: MRI findings of uterine lipoleiomyoma
▪ Chronic pelvic discomfort correlated with pathologic findings. AJR Am J Roentgenol.
▪ Heaviness 189(2):W100-4, 2007
▪ Pressure 16. Wang X et al: Uterine lipoleiomyomas: a clinicopathologic
▪ Uterine bleeding study of 50 cases. Int J Gynecol Pathol. 25(3):239-42, 2006
17. Aslan E et al: Lipoleiomyoma of the uterus: A diagnostic
Demographics problem. J Obstet Gynaecol. 25(6):610-1, 2005
• Age 18. Lau LU et al: Case report. Uterine lipoma: advantage of MRI
o Most occur in postmenopausal women over ultrasound. Br J Radiol. 78(925):72-4, 2005
• Epidemiology 19. Maebayashi T et al: Radiologic features of uterine
o 0.03-0.2% of hysterectomy specimens lipoleiomyoma. J Comput Assist Tomogr. 27(2):162-5, 2003
20. Avritscher R et al: Lipoleiomyoma of the uterus. AJR Am J
Natural History & Prognosis Roentgenol. 177(4):856, 2001
• Almost invariably benign 21. Prieto A et al: Uterine lipoleiomyomas: US and CT findings.
• Rare case reports of intravascular lipoleiomyomatosis

Abdom Imaging. 25(6):655-7, 2000
• Rare reports of liposarcoma arising in lipoleiomyoma

Treatment
• None if asymptomatic
• Hysterectomy in selected symptomatic patients
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Uterus
(Left) Axial T1WI FSE MR image
shows a round hyperintense
mass in the uterus . (Right)
Axial T1WI C+ FS MR image
shows near complete fat
saturation of the uterine
hyperintense mass
corresponding to macroscopic
fat. Surgical resection of the mass
proved to be lipoleiomyoma.

well-defined, hyperintense mass
of the myometrium in this 42-
year-old woman. (Right) Axial
T2WI FS MR shows complete fat
saturation of the T1 hyperintense
mass , due to the presence of
macroscopic fat in this patient
with lipoleiomyoma.
(Left) Axial CECT of the pelvis

demonstrates a large, fatty
mass in the superior uterus
as well as a low attenuation
homogeneous mass in the
lower uterine segment .
Surgical pathology proved to
be lipoleiomyoma and simple
leiomyoma. (Right) Sagittal
CECT MPR shows both the fatty
lipoleiomyoma and the lower
simple leiomyoma .
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Uterus ENDOMETRIAL POLYPS
Key Facts
Terminology • SHG: Homogeneous echogenic polypoid lesion, ±
• Localized hyperplastic growth of irregularly distributed vascular pedicle within stalk
endometrial glands and stroma Top Differential Diagnoses
Imaging • Focal endometrial hyperplasia
• Focal endometrial thickening or intracavitary mass • Submucosal leiomyoma
• Pedunculated or sessile • Polypoid adenomyoma
• Intratumoral cysts • Endometrial carcinoma
• Vascular fibrous stalk • Hematometra
• Most commonly cornual or fundal origin Pathology
• Rarely may prolapse through cervix • Pre- and postmenopausal women
• 1 mm to a few cm, multiple polyps in 20% of patients • Associated with tamoxifen and HRT
• CT: Enhancing mass hyperdense to endometrium • Rarely harbors atypia or carcinoma
• T1: Isointense to endometrium, ± hemorrhagic foci
• T2: Slightly hypointense to endometrium, ± cysts, ± Clinical Issues
fibrous core • Most asymptomatic
• US: Echogenic focal endometrial thickening or mass, ± • Dysfunctional uterine bleeding
cysts, ± vascular pedicle

ultrasound of the uterus shows
focal echogenic endometrial
thickening in the fundus
with central cystic change
. (Right) Transverse
transvaginal ultrasound of the
uterus at the fundus shows
homogeneously echogenic
endometrial thickening
with central cystic change
. The presence of cystic
change is highly suggestive of
an endometrial polyp resulting
in the focal endometrial
thickening.

FSE MR (same patient) shows
an intracavitary mass ,
hypointense to endometrium
with a central hyperintense
focus corresponding
to the central cyst seen on
sonography. (Right) Coronal
oblique T1WI C+ FS MR
shows the mass enhances
less than the surrounding
normal endometrium.
Note hypointensity of the
central cyst . Incidental
corpus luteum is noted
in right ovary. MR further
supports the diagnosis of
endometrial polyp, confirmed
2 by pathology.
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ENDOMETRIAL POLYPS
Uterus
o Endometrial-myometrial interface is preserved
TERMINOLOGY o Normal thickness uninvolved endometrium
Definitions
• Localized hyperplastic growth of irregularly distributed • Best imaging tool
endometrial glands and stroma
o TVS: Modality of choice with 56-96% sensitivity and
82% specificity
IMAGING o SHG: Consider using when TVS is suboptimal or
shows nonspecific thickening of endometrium
General Features
o TVS: Color Doppler and 3D ultrasound may help
o Focal endometrial thickening or mass
narrow differential of otherwise nonspecific
o Intratumoral cysts
▪ Variable size, well defined, smooth walled o SHG: Optimal distension of uterine cavity with
▪ Represent dilated endometrial glands
normal saline is mandatory
o Vascular fibrous stalk o MR: T2FSE is most important, obtain multiple planes
• Location
o Intracavitary lesion
o Most commonly cornual or fundal origin DIFFERENTIAL DIAGNOSIS
o Rarely may prolapse through cervix
Focal Endometrial Hyperplasia
• Size
• Cannot be differentiated from small broad-based polyp
o 1 mm to a few cm
on imaging
o Multiple polyps in 20% of patients
• Morphology Submucosal Leiomyoma
o Pedunculated • Hypoechoic shadowing mass, usually larger
o Sessile • Multiple feeding vessels penetrating mass from inner
myometrium
CT Findings
• CECT • Intact endometrium over lesion indicating
extraendometrial location on SHG
o Often not detectable on CT
o Enhancing central uterine mass • Broad attachment
o Hyperdense relative to normally hypodense • Continuity with myometrium
endometrium in portal venous phase Polypoid Adenomyoma
MR Findings • Can be identical to endometrial polyp
• T1WI • 2% of polyps are adenomyomas
o Intermediate signal intensity (SI), isointense to Endometrial Carcinoma
endometrium
o May have hemorrhagic foci
• Myometrial invasion is highly suggestive of carcinoma
• • May have central necrosis
T2WI
o Slightly hypointense to endometrium • No intratumoral cyst or fibrous core
o Heterogeneous ↑ SI • Small stage IA is difficult to differentiate
▪ Hyperintense intratumoral cysts Hematometra
▪ Hypointense fibrous core • Complete endometrial stripe surrounding clot
o Small polyps without cysts or fibrous core not seen
▪ Indistinguishable from surrounding endometrium
• No internal vascularity
• T1WI C+ FS
o Homogeneous or heterogeneous enhancement PATHOLOGY
o Small polyps seen best against hypointense
General Features
endometrium on early arterial phase
o Later phase may show focal endometrial thickening • Occurs in both pre- and postmenopausal women
• 20% multiple
Ultrasonographic Findings • Develop in 8-36% of postmenopausal women on
• Grayscale ultrasound tamoxifen
o Echogenic focal endometrial thickening or mass o More likely to be multiple or large or have metaplasia
o ± intratumoral cysts • Associated with hormone replacement therapy
o Hypoechoic or heterogeneous echotexture is atypical
• Rarely harbor atypia or carcinoma
• Color Doppler o Hyperplasia with atypia in 3.1-4.7%
o Single feeding artery (usually functional type) o Cancerous foci in 0.8-1.4%
o ~ 1/2 of polyps show no flow (usually atrophic type) o Endometrioid > serous carcinoma
• Sonohysterography (SHG) o Serous carcinoma usually in elderly
o Well-defined homogeneous polypoid lesion
o Less commonly broad based or sessile
• Hyperplastic polyps
o Resemble glands in endometrial hyperplasia
o Isoechoic to endometrium
• Atrophic polyps
o Vascular pedicle within stalk o Composed of atrophic cystically dilated glands 2
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o Occur in postmenopausal women

SELECTED REFERENCES
• Functional polyp
o Rare, follow cyclic endometrial changes 1. Fang L et al: Value of 3-dimensional and power Doppler
sonography for diagnosis of endometrial polyps. J
Gross Pathologic & Surgical Features Ultrasound Med. 32(2):247-55, 2013
• Usually smooth surfaced mass 2. Kabil Kucur S et al: Role of endometrial power Doppler
ultrasound using the international endometrial tumor
o May have surface erosion or infarction
analysis group classification in predicting intrauterine
o May see cysts on cut surface pathology. Arch Gynecol Obstet. 288(3):649-54, 2013
• Sessile or pedunculated 3. Hase S et al: Endometrial polyps: MR imaging features. Acta
• Thick or slender stalk
4.
Med Okayama. 66(6):475-85, 2012
Van Den Bosch T et al: Effect of gel-instillation sonography
Microscopic Features on Doppler ultrasound findings in endometrial polyps.
• 3 components Ultrasound Obstet Gynecol. 38(3):355-9, 2011
o Stroma consisting of dense fibrous or smooth muscle 5. Cil AP et al: Power Doppler properties of endometrial polyps
and submucosal fibroids: a preliminary observational study
tissue in women with known intracavitary lesions. Ultrasound
o Thick-walled vessels often in stalk
Obstet Gynecol. 35(2):233-7, 2010
o Disorganized endometrial glands 6. Steinkeler JA et al: Female infertility: a systematic approach
to radiologic imaging and diagnosis. Radiographics.
29(5):1353-70, 2009
CLINICAL ISSUES 7. Tamura-Sadamori R et al: The sonohysterographic difference
in submucosal uterine fibroids and endometrial polyps
Presentation
treated by hysteroscopic surgery. J Ultrasound Med.
26(7):941-6; quiz 947-8, 2007
o Most asymptomatic 8. Valenzano MM et al: The value of sonohysterography in
o Dysfunctional uterine bleeding detecting intracavitary benign abnormalities. Arch Gynecol
▪ Postmenopausal bleeding (30% due to polyps) Obstet. 272(4):265-8, 2005
▪ Menorrhagia or menometrorrhagia 9. Davis PC et al: Sonohysterographic findings of endometrial
▪ Intermenstrual bleeding and subendometrial conditions. Radiographics.
• Other signs/symptoms 10.

22(4):803-16, 2002
Goldstein SR et al: Evaluation of endometrial polyps. Am J
o Mucous discharge Obstet Gynecol. 186(4):669-74, 2002
o Infertility 11. Jorizzo JR et al: Endometrial polyps: sonohysterographic
• Clinical profile evaluation. AJR Am J Roentgenol. 176(3):617-21, 2001
o Often incidental finding on TVS 12. Caspi B et al: The bright edge of the endometrial polyp.
o Frequently missed on Pipelle biopsy or D&C Ultrasound Obstet Gynecol. 15(4):327-30, 2000
13. Dijkhuizen FP et al: Comparison of transvaginal
o Hysteroscopy most accurate diagnostic tool
ultrasonography and saline infusion sonography for the
Natural History & Prognosis detection of intracavitary abnormalities in premenopausal
• No indication of transformation to endometrial cancer women. Ultrasound Obstet Gynecol. 15(5):372-6, 2000
• Slow growth
14. Grasel RP et al: Endometrial polyps: MR imaging features
and distinction from endometrial carcinoma. Radiology.
• 15-35% of patients with endometrial cancer have 214(1):47-52, 2000
associated polyp(s) 15. Strauss HG et al: Significance of endovaginal
• Develop more cystic changes and become less vascular ultrasonography in assessing tamoxifen-associated changes
of the endometrium. A prospective study. Acta Obstet
post menopause
• Small polyps may slough with menstruation 16.
Gynecol Scand. 79(8):697-701, 2000
Baldwin MT et al: Focal intracavitary masses recognized
Treatment with the hyperechoic line sign at endovaginal US and
• Progestin therapy characterized with hysterosonography. Radiographics.
• Polypectomy, if benign
19(4):927-35, 1999
17. Farrell T et al: The significance of an 'insufficient' Pipelle
• Hysterectomy, if atypical hyperplasia or carcinoma in sample in the investigation of post-menopausal bleeding.
polyp Acta Obstet Gynecol Scand. 78(9):810-2, 1999
• Observation in older asymptomatic patients 18. La Torre R et al: Transvaginal sonographic evaluation of
endometrial polyps: a comparison with two dimensional
and three dimensional contrast sonography. Clin Exp
DIAGNOSTIC CHECKLIST Obstet Gynecol. 26(3-4):171-3, 1999
19. Laifer-Narin SL et al: Transvaginal saline hysterosonography:
Consider characteristics distinguishing malignant and various benign
• SHG if endometrial thickening without cystic change 20.
conditions. AJR Am J Roentgenol. 172(6):1513-20, 1999
Senoh D et al: Clinical application of intrauterine
and vascular pedicle
• MR if cervical stenosis precludes SHG sonography with high-frequency, real-time miniature
transducer in gynecologic disorders. Preliminary report.
Image Interpretation Pearls Gynecol Obstet Invest. 47(2):108-13, 1999
• Focal echogenic endometrial thickening with cystic 21. Smith-Bindman R et al: Endovaginal ultrasound to exclude
endometrial cancer and other endometrial abnormalities.
change and single feeding vessel JAMA. 280(17):1510-7, 1998
22. Atri M et al: Transvaginal US appearance of endometrial
abnormalities. Radiographics. 14(3):483-92, 1994
2
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ENDOMETRIAL POLYPS
Uterus
homogeneous diffuse echogenic
thickening of the endometrial
echo complex. (Right)
Longitudinal sonohysterogram in
the same patient demonstrates
2 pedunculated endometrial
polyps and normal thin
endometrial lining . Multiple
polyps are seen in 20% of cases.

ultrasound shows focal
endometrial thickening ,
which is nonspecific and may
represent an endometrial polyp,
focal hyperplasia, or carcinoma.
(Right) Axial oblique T2WI
FSE MR in the same patient
shows a pedunculated polypoid
endometrial mass with a
low-signal stalk . The mass is
hypointense on T2 relative to the
normally bright endometrium
.
(Left) Axial oblique T2WI FSE

MR of the endometrial mass
shows internal high-signal foci
consistent with intratumoral cysts
, which correspond to dilated
endometrial glands. (Right) Axial
T1WI FS MR of the endometrial
mass shows high-signal foci
representing hemorrhage. The
MR shows that an endometrial
polyp corresponds to the focal
thickening seen on US. This was
pathologically confirmed due
to the patient's symptoms of
bleeding and the small risk of
polyps harboring endometrial
cancer.
2
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ultrasound shows focal
echogenic endometrial
thickening . This grayscale
appearance may be seen
with an endometrial polyp,
hyperplasia, or carcinoma.
Unfortunately endometrial
biopsy has poor sensitivity
for focal intracavitary lesions.
(Right) Longitudinal color
Doppler ultrasound of the
area of endometrial thickening
shows a single vascular pedicle
favoring the diagnosis of
endometrial polyp.

ultrasound shows thickening of
the endometrial echo complex
. (Right) 3D ultrasound
shows the endometrial
thickening is due to an
echogenic oval polypoid
endometrial mass .
(Left) Coronal CECT in

an enhancing polypoid
endometrial mass .
Although not the first-line
imaging modality, polyps may
be seen on CT as enhancing
masses against the normally
hypoenhancing endometrium.
(Right) Axial CECT shows
the endometrial polyp
similar to the 3D ultrasound.
Visualization of a polyp on
CT is dependent on the
phase of contrast and phase
of menstruation to allow
differential enhancement of
polyp and endometrium.
2
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ENDOMETRIAL POLYPS
Uterus
(Left) Longitudinal
sonohysterogram shows a
sessile endometrial lesion
at the uterine fundus.
Sonohysterography helps
in evaluating nonspecific
endometrial thickening, triaging
patients to endometrial biopsy
for diffuse abnormalities,
and in hysteroscopy for focal
abnormalities. (Right) 3D
shows the sessile endometrial
lesion to better advantage.
3D ultrasound is a useful adjunct
to both routine sonography
and sonohysterography when
evaluating the endometrial
cavity.
(Left) Transverse
sonohysterogram shows a
polypoid echogenic endometrial
mass with hypoechoic
foci. Internal cystic change
corresponds to dilated
endometrial glands in this
patient with an endometrial
polyp. (Right) 3D ultrasound
endometrial cavity distended
with fluid , the catheter
balloon at the internal
cervical os, and the endometrial
polyp .

a linear hypointense lesion
in the endometrial cavity
of the lower uterine segment
representing the fibrous stalk of
an endometrial polyp prolapsing
into the cervix. (Right) Axial
T2WI FSE MR in the same patient
shows the endometrial polyp
expanding the endocervical
canal. Note the intratumoral
cysts .
2
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Uterus ENDOMETRIAL HYPERPLASIA
Key Facts
Terminology • Endometrial polyp
• Excessive proliferation of endometrial glands with • Endometritis
increased ratio of glands to stroma • Submucosal leiomyoma
Imaging Pathology
• Endometrial thickening, focal or diffuse • Unopposed estrogen stimulation
• Well-defined endometrial-myometrial interface • Accounts for 4-8% of cases of postmenopausal bleeding
• May show cystic changes ("swiss cheese" appearance) • Endometrial hyperplasia without cellular atypia
• TVUS along with SHG (if individual layers are not seen o Small (< 2%) risk of endometrial carcinoma
on TVUS) are best screening tools • Endometrial hyperplasia with cellular atypia or
• SHG helps triage patients to office Pipelle vs. atypical hyperplasia
hysteroscopically-guided biopsy o 25% harbor coexisting foci of endometrial
• MR may miss endometrial abnormalities carcinoma or will develop carcinoma in future
• MR useful in suspected submucosal leiomyoma Diagnostic Checklist
Top Differential Diagnoses • Cannot differentiate from endometrial cancer on
• Secretory endometrium imaging; must get biopsy
• Endometrial carcinoma
(Left) Longitudinal TVUS

in a patient with breast
cancer on tamoxifen shows
diffuse thickening of the
endometrial stripe with
punctate anechoic foci .
(Right) Transverse TVUS
shows cystic change in the
thickened endometrium
compatible with dilation of the
endometrial glands. Although
this appearance is typical
of endometrial hyperplasia
in a patient on tamoxifen,
endometrial cancer cannot
be excluded by imaging
alone; therefore, biopsy was
recommended to confirm.

the thickened endometrium
; however, the small cystic
changes are difficult to see
with the lower resolution of
MR. The cyst projecting
into the subendometrium is
seen well in the background of
the low-signal junctional zone.
MR shows the nonenhancing
cystically dilated endometrial
glands to better advantage.
These images also demonstrate
how bladder filling during
the MR exam can be used to
reduce uterine anteversion
2 when needed.
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ENDOMETRIAL HYPERPLASIA
Uterus
o TVUS along with SHG (if individual layers are not
TERMINOLOGY
seen on TVUS) are best screening tools
Definitions o SHG helps triage patients to office Pipelle vs.
• Excessive proliferation of endometrial glands with hysteroscopically-guided biopsy
o MR may miss endometrial abnormalities
increased ratio of glands to stroma
o MR useful in suspected submucosal leiomyoma
IMAGING • Protocol advice

o Measure ET where outer contours of 2 layers of
General Features endometrium parallel each other
• Best diagnostic clue o Subtract fluid within endometrial cavity for
o Endometrial thickening with well-defined measuring ET
o Focal fundal endometrial thickening when
myometrial interface
o Focal or diffuse endometrium is thin in lower uterine segment may
o May show cystic change (dilated endometrial glands) be normal variant
• Thresholds for abnormal uniform endometrial
thickening (ET) DIFFERENTIAL DIAGNOSIS
o Premenopausal women
▪ ET > 8 mm during proliferative phase Secretory Endometrium
▪ ET > 16 mm during secretory phase • Imaging findings overlap with findings of hyperplasia
o Postmenopausal women with bleeding (Society of • Resolves on follow-up US obtained early in next
Radiologists in Ultrasound consensus) menstrual cycle
▪ ET > 5 mm
o Postmenopausal women without bleeding (no Endometrial Carcinoma
consensus) • May coexist with endometrial hyperplasia
▪ Various reports suggest ET > 8-11 mm • Imaging findings can overlap with those of hyperplasia
o These thresholds cannot be used for focal in 30% of cases
endometrial thickening, mass, or heterogeneity • Irregular endometrial thickening ± mass
• Ill-defined margins, myometrial invasion is diagnostic
MR Findings
• T1WI • TVUS: Heterogeneous with areas of decreased
echogenicity (60%)
o Usually not seen due to isointensity of endometrium
• MR
to myometrium o T2WI: Hypointense relative to normal endometrium
• T2WI o T1WI C+ FS: Hypointense relative to myometrium
o Diffuse thickening of endometrial stripe
▪ Isointense or slightly hypointense relative to Endometrial Polyp
normal endometrium • May coexist with endometrial hyperplasia
▪ May show cystic changes (small hyperintense foci) • Sessile polyps may mimic appearance of focal
• T1WI C+ FS endometrial hyperplasia
o Early C+: Hypointense relative to myometrium • Separate endometrial lining (hyperechoic line sign)
o Delayed C+: Iso- or hyperintense relative to • Color Doppler: Single feeding vessel in pedunculated
myometrium polyp
o May show cystic changes (small hypointense foci) • SHG: Highest accuracy for differentiating hyperplasia
from large endometrial polyp filling endometrial cavity
• Grayscale ultrasound • Fibrous stalk on MR
o Diffusely thickened, homogeneously echogenic Endometritis
endometrium • Diffuse hypervascular endometrial thickening
o Focal endometrial thickening is less common • Uterine cavity fluid
o May show cystic changes (small anechoic foci), "swiss
• Adnexal changes of pelvic inflammatory disease
cheese" appearance
o Uncommonly hypoechoic/heterogeneous areas may • Clinical presentation and endometrial sampling help
differentiation
be present with atypical hyperplasia
• Sonohysterography (SHG) Submucosal Leiomyoma
o Similar findings to TVUS • Focal hypoechoic thickening of endometrial echo
o Differentiates diffuse from focal endometrial complex
thickening • MR can easily differentiate from hyperplasia and polyp
• Color and power Doppler
o No definite criteria to reliably differentiate
PATHOLOGY
hyperplasia from carcinoma
o Multiple feeding vessels, sparse vascularity General Features
Imaging Recommendations • Etiology
o Unopposed estrogen stimulation
• Best imaging tool ▪ Chronic anovulatory states
▪ Unopposed exogenous estrogen use
2
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Uterus ENDOMETRIAL HYPERPLASIA
▪ Tamoxifen • Hyperplasia with atypia

▪ Obesity o Curettage or simple hysterectomy, depending on
▪ Estrogen-secreting ovarian tumors patient age
• Associated abnormalities • Hyperplasia in patients on HRT
o Endometrial polyp o Cessation of HRT and rebiopsy
o Endometrial cancer
▪ 95% have vaginal bleeding
▪ Up to 1/3 are preceded by endometrial hyperplasia DIAGNOSTIC CHECKLIST
• Accounts for 4-8% of cases of postmenopausal bleeding Consider
• Broadly classified into 2 categories • SHG if central interface is not seen in its entirety on
o Endometrial hyperplasia without cellular atypia TVS, and therefore 2 layers of endometrium are not
▪ Risk of endometrial carcinoma is small (< 2%) seen distinctly
▪ Trial of progesterone therapy with follow-up
transvaginal sonography (TVS) ± endometrial Image Interpretation Pearls
biopsy • Diffuse or focal endometrial thickening ± cystic change
o Endometrial hyperplasia with cellular atypia or • Cannot differentiate from endometrial cancer on
atypical hyperplasia imaging; must get biopsy
▪ 25% harbor coexisting foci of endometrial • Consider degree of endometrial thickening in light of
carcinoma or will develop endometrial carcinoma patient risk factors
in future • MR may look normal or show homogeneous
endometrial thickening (cysts may be beyond
Staging, Grading, & Classification resolution of MR)
• Hyperplasia without atypia
o Simple hyperplasia
o Complex hyperplasia SELECTED REFERENCES
• Hyperplasia with atypia 1. Giannella L et al: Diagnostic accuracy of endometrial
thickness for the detection of intra-uterine pathologies
Gross Pathologic & Surgical Features and appropriateness of performed hysteroscopies among
• Diffuse endometrial hyperplasia is not distinctive asymptomatic postmenopausal women. Eur J Obstet
Gynecol Reprod Biol. 177:29-33, 2014
grossly, but focal hyperplasia can simulate a polyp
2. Griffin Y et al: Radiology of benign disorders of
Microscopic Features menstruation. Semin Ultrasound CT MR. 31(5):414-32,
• Increase in number of glands relative to stroma 2010
o Simple hyperplasia: Gross or minimally cystically 3. Smith-Bindman R et al: How thick is too thick? When
endometrial thickness should prompt biopsy in
dilated glands
postmenopausal women without vaginal bleeding.
o Complex hyperplasia: Highly complex, crowded
Ultrasound Obstet Gynecol. 24(5):558-65, 2004
glands with epithelial stratification but little stroma 4. Davidson KG et al: Ultrasonographic evaluation of the
o Hyperplasia with atypia: Increase in number of endometrium in postmenopausal vaginal bleeding. Radiol
glands lined by cells displaying cytologic atypia Clin North Am. 41(4):769-80, 2003
5. Williams PL et al: US of abnormal uterine bleeding.
Radiographics. 23(3):703-18, 2003
CLINICAL ISSUES 6. Davis PC et al: Sonohysterographic findings of endometrial
and subendometrial conditions. Radiographics.
Presentation 22(4):803-16, 2002
• Most common signs/symptoms 7. Gupta JK et al: Ultrasonographic endometrial thickness
o Bleeding, especially in postmenopausal women for diagnosing endometrial pathology in women with
• Other signs/symptoms postmenopausal bleeding: a meta-analysis. Acta Obstet
o Menorrhagia, menometrorrhagia Gynecol Scand. 81(9):799-816, 2002
8. Jorizzo JR et al: Spectrum of endometrial hyperplasia and its
Demographics mimics on saline hysterosonography. AJR Am J Roentgenol.
• Epidemiology 9.
179(2):385-9, 2002
Reinhold C et al: Postmenopausal bleeding: value of
o Risk factors
imaging. Radiol Clin North Am. 40(3):527-62, 2002
▪ Nulliparity 10. Goldstein RB et al: Evaluation of the woman with
▪ Obesity (10x) postmenopausal bleeding: Society of Radiologists in
▪ Hypertension Ultrasound-Sponsored Consensus Conference statement. J
▪ Diabetes mellitus (3x) Ultrasound Med. 20(10):1025-36, 2001
▪ Tamoxifen (2x) 11. Nalaboff KM et al: Imaging the endometrium: disease and
▪ Age > 70 years normal variants. Radiographics. 21(6):1409-24, 2001
o Long-term use of oral contraceptives decreases risk 12. Smith-Bindman R et al: Endovaginal ultrasound to exclude
endometrial cancer and other endometrial abnormalities.
Natural History & Prognosis JAMA. 280(17):1510-7, 1998
• Prognosis is excellent with early detection and 13. Lerner JP et al: Use of transvaginal sonography in the
evaluation of endometrial hyperplasia and carcinoma.
appropriate treatment Obstet Gynecol Surv. 51(12):718-25, 1996
Treatment
• Simple and complex hyperplasia
2 o Conservative or hormonal therapy
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ENDOMETRIAL HYPERPLASIA
Uterus
(Left) Longitudinal TVUS of the
uterus shows focal thickening
of the endometrium with
tiny anechoic cystic spaces
. Note the thin lower stripe
and nabothian cyst .
(Right) Transverse TVUS
in the same patient at the
level of the thickened cystic
endometrium has the typical
"swiss cheese" appearance of
endometrial hyperplasia. The
findings of focal hyperplasia
overlap with endometrial polyps
and cancer. Confirmation with
biopsy is necessary, and in
the case of focal hyperplasia,
it is best performed with
hysteroscopic guidance.
(Left) Longitudinal TVUS of

the uterus shows echogenic
echo complex , measuring
19 mm in this premenopausal
female. (Right) Transverse
TVUS in the same patient shows
homogeneous thickening of the
endometrium , which can be
sampled with blind endometrial
biopsy due to the diffuse nature
of the abnormality.
(Left) Longitudinal TVUS of

the uterus in a premenopausal
female shows both punctate
and small cysts in the
endometrial echo complex .
Although not thickened at 13
mm, the heterogeneous and
cystic appearance is abnormal.
Endometrial polyp and cancer
must be excluded with biopsy.
(Right) Transverse color Doppler
shows no significant blood
flow in the cystic endometrium
. Endometrial hyperplasia
is typically hypovascular, as
opposed to the single feeding
artery seen with polyps.
2
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Uterus ADENOSARCOMA
Key Facts
Terminology • MR is most accurate imaging technique for evaluation
• Uterine tumor composed of benign glandular elements of myometrial invasion
o Regions of high T1 signal intensity representing
(epithelium) and malignant stroma (sarcoma)
hemorrhage within tumor
Imaging o Heterogeneous mass of high signal intensity
• Heterogeneous, polypoid mass containing numerous Pathology
thin septa, creating lattice-like appearance and
expanding endometrial cavity • Association with tamoxifen therapy for breast cancer
• 90% endometrial; 10% endocervical • May be associated with long-term use of oral
• May sometimes originate from foci of adenomyosis if contraceptives
• Endometrial polyps
arising from myometrium
• Variable size, but often large, reaching up to 9 cm Clinical Issues
• Mass may protrude through cervical os
• Accounts for only 8% of all uterine sarcomas
• Presence of peritoneal implants
• Postmenopausal bleeding
• Transvaginal ultrasound should be used for
initial investigation of women who present with
postmenopausal bleeding
(Left) Axial CECT image of the

pelvis shows a large soft tissue
mass replacing the endometrial
cavity and invading the
uterine myometrium .
Enhancing linear regions
produce a lattice appearance
to the mass in this patient
with adenosarcoma. (Right)
Axial CECT image in a
postmenopausal woman
who presented with pelvic
pain shows soft tissue
expanding and replacing
the uterine cavity and
thinning of myometrium .
Hysterectomy pathology
proved adenosarcoma of the
uterus.

ultrasound image demonstrates
echogenic expansion
and replacement of the
endometrial cavity , with a
more focal hypoechoic mass
within the cavity in this
72-year-old postmenopausal
woman who presented
with vaginal bleeding.
Surgical pathology proved
adenosarcoma of the uterus.
(Right) Axial CECT in a patient
with vaginal bleeding shows
a large heterogeneous mass
replacing the uterus and
filling in the pelvic inlet.
Surgical resection proved to be
2 adenosarcoma.
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ADENOSARCOMA
Uterus
o Small hypoechoic cystic areas maybe present
TERMINOLOGY o Poorly defined endometrial tumor/myometrium
Definitions interface
• Müllerian adenosarcoma of uterus • Color Doppler
• Uterine tumor composed of benign glandular elements o Vascular pedicle entering mass may be seen in cases
(epithelium) and malignant stroma (sarcoma) of adenosarcoma arising from an adenomatous polyp
IMAGING • Best imaging tool
o Transvaginal ultrasound should be used for
General Features
• Best diagnostic clue
initial investigation of women who present with
o Heterogeneous, polypoid mass containing numerous o MR is most accurate imaging technique for
thin septa creating lattice-like appearance and evaluation of myometrial invasion
expanding endometrial cavity
• Protocol advice
• Location o DCE-MR in sagittal and axial planes to accurately
o 90% endometrial; 10% endocervical
demonstrate presence of myometrial invasion
o May originate from foci of adenomyosis if arising
from myometrium
o Variable, but often large, reaching up to 9 cm
Adenomatous Polyp
• Morphology
• Can be indistinguishable from adenosarcoma;
o Heterogeneous enhancing polypoid mass expanding
however, presence of myometrial invasion indicates
endometrial cavity and protruding through dilated adenosarcoma
cervical canal
Endometrial Carcinoma
CT Findings
• Thickened endometrium of intermediate signal
• NECT intensity on T2WI MR
o Uterine enlargement
o Regions of necrosis Malignant Mixed Müllerian Tumor
• CECT • Large solid mass replacing endometrial cavity; necrosis
o Large uterine mass or multiple solid masses and hemorrhage are prominent features
expanding endometrial canal • Lymph node metastases and peritoneal seeding are
o Heterogeneous enhancement common
o Regions of necrosis Other Uterine Sarcomas
MR Findings • Uterine sarcomas tend to be larger, heterogeneous, and
• T1WI more aggressive
o Enlarged uterus Adenomyosis
o Intermediate signal intensity heterogeneous mass
o Regions of high signal intensity representing
• Diffuse or focal involvement of myometrium,
containing ill-defined low signal intensity with
hemorrhage within tumor multifocal high signal intensity foci on T2WI
• T2WI
o Expansion of endometrial cavity
o Heterogeneous mass of high signal intensity PATHOLOGY
o Single or multiple polypoid masses of heterogeneous General Features
signal intensity
o Mass can protrude through cervical os • Etiology
o Association with tamoxifen therapy in treatment of
o May contain multiple necrotic (cystic) regions
breast carcinoma
o Loss of low signal intensity junctional zone indicates
o May be associated with long-term use of oral
myometrial invasion
•
contraceptives
T1WI C+ FS
o Avid enhancement of single or multiple polypoid • Associated abnormalities
o Endometrial polyps
uterine masses
o Enhancement of solid components and thin septa Gross Pathologic & Surgical Features
traversing endometrial canal, creating a lattice-like • Polypoid endometrial neoplasm that grows into uterine
appearance cavity
o Disruption of subendometrial enhancement band • Sectioned surface is frequently spongy, containing
indicates myometrial invasion cystic spaces filled with fluid, with surrounding white/
o Presence of peritoneal implants tan tissue
Ultrasonographic Findings Microscopic Features
• Grayscale ultrasound • Biphasic tumor composed of benign glands
o Expansion of endometrial cavity (epithelium) with malignant stroma (sarcoma)
o Thickened heterogeneous endometrium
2
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Uterus ADENOSARCOMA
• Glands are often cystically dilated or form cleft-like SELECTED REFERENCES

spaces
• Glands can be endometrial (proliferative or secretory), 1. Chin PS et al: Diagnosis and management of Müllerian
adenosarcoma of the uterine cervix. Int J Gynaecol Obstet.
endocervical, tubal, or hobnail in type
• Mesenchymal component consists of malignant 2.
121(3):229-32, 2013
Hirschowitz L et al: Intravascular adenomyomatosis:
spindle or round cells and tends to show a greater expanding the morphologic spectrum of intravascular
cellularity around glands (glandular cuffing) leiomyomatosis. Am J Surg Pathol. 37(9):1395-400, 2013
• 20% have heterologous elements, i.e., tissue types 3. Lee TY et al: Synchronous occurrence of primary malignant
not normally found in uterus (e.g., fat, cartilage, mixed müllerian tumor in ovary and uterus. Obstet Gynecol
rhabdomyoblasts) Sci. 56(4):269-72, 2013
• Myometrial invasion is seen in ~ 15% and is usually 4. Novetsky AP et al: Management of sarcomas of the uterus.
Curr Opin Oncol. 25(5):546-52, 2013
superficial (confined to inner 1/2) in 80%
• 10% of cases show overgrowth of > 25% of tumor by a
5. Sutton G: Uterine sarcomas 2013. Gynecol Oncol.
130(1):3-5, 2013
pure sarcoma (sarcomatous overgrowth), giving a worse 6. Tanner EJ et al: Management of uterine adenosarcomas
prognosis with and without sarcomatous overgrowth. Gynecol Oncol.
129(1):140-4, 2013
7. Tirumani SH et al: Current concepts in the imaging of
CLINICAL ISSUES uterine sarcoma. Abdom Imaging. 38(2):397-411, 2013
8. Yu J et al: [Clinicopathologic characteristics of Müllerian
Presentation
adenosarcoma of uterus:a comparative analysis of 7 cases
before and after surgery.] Zhonghua Bing Li Xue Za Zhi.
o Postmenopausal bleeding 42(8):547-8, 2013
• Other signs/symptoms 9. Akhavan A et al: Uterine adenosarcoma in a patient
o Pelvic mass with history of breast cancer and long-term tamoxifen
o Pelvic pain consumption. BMJ Case Rep. 2012
10. Tropé CG et al: Diagnosis and treatment of sarcoma of the
Demographics uterus. A review. Acta Oncol. 51(6):694-705, 2012
• Age 11. Sameshima N et al: So-called 'adenosarcoma' of the kidney a
o Range: 13-67 years novel adult renal tumor with a cystic appearance. Pathol Int.
•
61(5):313-8, 2011
Epidemiology 12. Yoshizako T et al: MR imaging of uterine adenosarcoma:
o Accounts for only 8% of all uterine sarcomas case report and literature review. Magn Reson Med Sci.
o Patients with adenosarcoma have a higher incidence 10(4):251-4, 2011
of thyroid cancer, benign ovarian cyst, and polycystic 13. Takeuchi M et al: Adenosarcoma of the uterus: magnetic
ovarian disease compared to general population resonance imaging characteristics. Clin Imaging.
o Previous pelvic radiation has been reported 33(3):244-7, 2009
14. Soh E et al: Magnetic resonance imaging findings of
Natural History & Prognosis tamoxifen-associated uterine Müllerian adenosarcoma: a
• Hematogenous metastases are extremely rare case report. Acta Radiol. 49(7):848-51, 2008
• Increased risk of recurrence if sarcomatous overgrowth 15. Tjalma WA et al: Mullerian adenosarcoma of the uterus
associated with long-term oral contraceptive use. Eur J
and myometrial invasion are present
• Local recurrence in 25% of cases
Obstet Gynecol Reprod Biol. 119(2):253-4, 2005
16. Crade M et al: Pedicle sign and diagnosis of endometrial
• Recurrence is mainly in vagina and pelvis (60%) adenosarcoma. J Ultrasound Med. 23(9):1217-9, 2004
• Tumor recurrence carries a bad prognosis 17. Lee EJ et al: Polypoid adenomyomas: sonohysterographic
and color Doppler findings with histopathologic
Treatment correlation. J Ultrasound Med. 23(11):1421-9; quiz 1431,
• Hysterectomy, bilateral oophorectomy, and lymph 18.
2004
Tinar S et al: Adenosarcoma of the uterus: a case report.
node sampling
• Chemotherapy and radiotherapy may be used if there is 19.
MedGenMed. 6(1):51, 2004
Chourmouzi D et al: Sonography and MRI of tamoxifen-
deep myometrial invasion or extrauterine spread associated mullerian adenosarcoma of the uterus. AJR Am J
Roentgenol. 181(6):1673-5, 2003
20. Rha SE et al: CT and MRI of uterine sarcomas and their
DIAGNOSTIC CHECKLIST mimickers. AJR Am J Roentgenol. 181(5):1369-74, 2003
Consider 21. Hann LE et al: Sonohysterography for evaluation of the
• Transvaginal ultrasound as initial imaging test in endometrium in women treated with tamoxifen. AJR Am J
Roentgenol. 177(2):337-42, 2001
women with abnormal uterine bleeding 22. Krivak TC et al: Uterine adenosarcoma with sarcomatous
• MR used for local staging and treatment planning overgrowth versus uterine carcinosarcoma: comparison of
treatment and survival. Gynecol Oncol. 83(1):89-94, 2001
Image Interpretation Pearls 23. Arici DS et al: Mullerian adenosarcoma of the uterus
• Heterogeneous mass resulting in expansion of associated with tamoxifen therapy. Arch Gynecol Obstet.
endometrial cavity 264(2):105-7, 2000
• Disruption of junctional zone and irregular tumor-
myometrium interface suggest myometrial invasion
2
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ADENOSARCOMA
Uterus
(Left) Axial CECT image shows
replacing the uterus with
large regions of necrosis
and soft tissue . There is
extension of the tumor beyond
the uterus in this patient with
adenosarcoma of the uterus.
(Right) Axial CECT demonstrates
replacing the uterine cavity and
myometrium and invading
the parametrial soft tissues and
pelvic side walls. Note the large
component of necrosis in this
patient with adenosarcoma.
(Left) Coronal CECT image in the

same patient shows the extent of
the large adenosarcoma of the
uterus . (Right) Axial CECT
of the pelvis in a patient with a
pelvic mass on physical exam
shows a large necrotic mass
involving the uterus and
adnexa .

patient shows a complex
heterogeneous mass in the
left adnexa with regions of
necrosis and soft tissue .
The endometrial cavity is also
expanded . Surgical resection
proved to be adenosarcoma.
(Right) Axial CECT image lower
down in the same patient shows
expansion of the endometrial
cavity with necrotic soft tissue
similar to the attenuation
of the left adnexal mass .
adenosarcoma of the uterus and
left adnexa.
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Uterus MALIGNANT MIXED MESODERMAL TUMOR
Key Facts
Terminology • Occurs in older, postmenopausal women
• Malignant mixed müllerian tumor, carcinosarcoma • Classified as homologous (tissue indigenous to uterus)
• Malignant neoplasms of uterus composed of both or heterologous (tissue foreign to uterus) based on
nature of sarcomatous element
carcinomatous (epithelial issue) and sarcomatous
(mesenchymal ) components Clinical Issues
Imaging • Pelvic pain, vaginal discharge, or mass protruding
• Arise anywhere in lower female genital tract but most through endocervical os
• Poor prognosis, with early development of metastases
common in uterus
• Heterogeneously enhancing large intracavitary "frond- • Surgery: Total abdominal hysterectomy and bilateral
like" uterine soft tissue mass, expanding endometrial salpingo-oophorectomy, pelvic and paraaortic
cavity with marked myometrial invasion lymphadenectomy
• Can be seen to prolapse through endocervical cavity • Preoperative and postoperative radiation treatment,
chemotherapy
Pathology
• Risk factors similar to endometrial carcinoma
o Includes obesity, exogenous estrogen therapies,
pelvic radiation, tamoxifen treatment, and
nulliparity

ultrasound image shows
a large, heterogeneous,
echogenic intracavitary
mass with regions of
cystic change expanding the
endometrial cavity. (Right)
ultrasound image in the
same patient centered at
the cervix shows the large,
heterogeneous, intracavitary
echogenic mass with
regions of cystic change
prolapsing and expanding
through the endocervical canal
in this patient surgically proven
to have a malignant mixed
mesodermal tumor.
(Left) Sagittal CECT in a

patient with MMMT shows a
large frond-like heterogeneous
mass with soft tissue and
necrotic components
expanding the endometrial
cavity and involving the
endocervical cavity. (Right)
shows the frond-like polypoid
nature of MMMT expanding
the endometrial cavity. Note
the enhancing soft tissue
components of this mass .
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MALIGNANT MIXED MESODERMAL TUMOR
Uterus
o Areas of necrosis could be seen as high signal
TERMINOLOGY
intensity regions within mass
Abbreviations ▪ Pelvic lymphadenopathy demonstrates similar
• Malignant mixed mesodermal tumor (MMMT) signal to primary mass
Synonyms
• DWI
o Primary tumor and metastases demonstrate marked
• Malignant mixed müllerian tumor diffusion restriction
• Carcinosarcoma • T1WI C+
o Heterogeneous enhancement to a lesser extent than
Definitions
• Malignant neoplasms of uterus composed of both adjacent normal myometrium
▪ Can be used to assess myometrial invasion
carcinomatous (epithelial issue) and sarcomatous
o Sagittal dynamic post-contrast images are very useful
(mesenchymal ) components
in assessment of depth of myometrial invasion
▪ Pelvic lymphadenopathy demonstrates similar
IMAGING enhancement to primary tumor
General Features Ultrasonographic Findings
• Best diagnostic clue • Grayscale ultrasound
o Broad-based large uterine mass with aggressive o Expansile intracavity uterine mass with regions of
myometrial invasion cystic and echogenic soft tissue
▪ Tumor expanding endometrial cavity ▪ Can be seen to extend and expand endocervical
– Frond-like soft tissue cavity
• Location o US is limited for staging of tumor, especially when
o May arise anywhere in lower female genital tract but mass is very large
most common in uterus • Color Doppler
• Size o Tumor vascularity can be detected
o Usually very large mass • Power Doppler
• Morphology o More sensitive to detect tumor vascularity
o Heterogeneous intracavitary mass expanding
Angiographic Findings
endometrial cavity
▪ Solid and cystic regions of necrosis expanding • Conventional
o Can show tumor vascularity
endometrial and endocervical cavity
o May protrude through cervical os Nuclear Medicine Findings
CT Findings • PET
o Can demonstrate avid FDG-18 uptake in primary
• NECT
tumor
o Difficult to differentiate mass from normal uterus
o Areas of hemorrhage within mass may demonstrate ▪ Useful in staging with avid FDG-18 uptake in
metastases to pelvic lymph nodes, liver, and lungs
high attenuation
• CECT Other Modality Findings
o Heterogeneously enhancing large intracavitary • 3D ultrasound imaging with volume contrast imaging
uterine soft tissue mass, expanding endometrial (VCI) can be useful for evaluation of myometrial
cavity invasion and cervical involvement
▪ Produces a frond-like appearance due to soft tissue
elements
– Invades and thins myometrium
o Areas of necrosis in mass do not demonstrate o Role of imaging is to define local extent and distant
enhancement metastases of disease for treatment planning
▪ Associated pelvic lymphadenopathy o MR is method of choice for evaluation of primary
– Metastases to lung and liver may be present tumor and of local extent of disease
o CT could be used in advanced cases with distant
MR Findings spread
• T1WI • Protocol advice
o Predominantly low signal intensity intracavitary o T1WI: Entire pelvis with large field of view
uterine mass o T2WI: Transverse, sagittal, and coronal planes with
o Areas of hemorrhage within mass may demonstrate small field of view
high signal intensity o T1WI C+: Dynamic post-contrast images in sagittal
• T2WI plane
o Heterogeneous isointense to high signal intensity ▪ Diffusion-weighted imaging useful
intracavitary uterine mass
▪ Can be seen to prolapse through endocervical
cavity
▪ Frond-like or polypoid soft tissue expanding
endometrial cavity
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DIFFERENTIAL DIAGNOSIS Staging, Grading, & Classification

Endometrial Carcinoma
• According to modification of FIGO staging system for
endometrial cancer
• MMMTs tend to be larger, heterogeneous and more o Stage I: Tumor is confined to uterine corpus
aggressive o Stage II: Tumor is confined to corpus and cervix
o MMMTs tend to expand endometrial cavity more o Stage III: Extrauterine disease is confined to pelvis
than adenocarcinoma o Stage IV: Abdominal and distant disease is present
▪ Adenocarcinoma usually does not prolapse into
the endocervical canal Gross Pathologic & Surgical Features
Leiomyosarcoma
• Large, friable, soft, polypoid, expansile intracavitary
endometrial masses invading into myometrium
• Difficult to differentiate from MMMT based on imaging o Often large enough to protrude through
• Both leiomyosarcomas and MMMTs are usually large endocervical os
and aggressive
o Both leiomyosarcoma and MMMT can present with
• Hemorrhage and necrosis are usually present
metastases to pelvic lymph nodes, lungs, and liver Microscopic Features

Endometrial Stromal Sarcoma
• Spectacular array of different and bizarre malignant
cells differentiating both as carcinoma and sarcoma
• Difficult to differentiate from MMMT based on imaging • Classified as homologous (tissue indigenous to uterus)
• Both endometrial stromal sarcomas and MMMTs are or heterologous (tissue foreign to uterus) based on
usually large and aggressive nature of sarcomatous element
Adenomyosis • Either carcinomatous or sarcomatous component may
• Adenomyosis infiltrates myometrium without

predominate
o Carcinomatous components include endometrioid
displacing endometrium
• Junctional zone is thickened in adenomyosis
adenocarcinoma, and poorly differentiated papillary
serous endometrial carcinoma
• Heterotopic endometrial tissue in adenomyosis has ▪ Epithelial component of tumor usually higher
characteristic appearance of hyperechoic foci on US incidence of myometrial invasion and metastases
and hyperintense foci on T2WI MR
o Myometrial cysts present in adenomyosis • Mixed tumors with homologous elements have a better
prognosis than those with heterologous elements
Leiomyoma • Sarcomatous component is either homologous or
• Leiomyomas typically show homogeneously low signal heterologous
o Homologous sarcomatous component is usually high
intensity on T2WI
• Degenerated leiomyomas with heterogeneous grade consisting of spindle cells, round cells, or giant
cells resembling fibrosarcoma or leiomyosarcoma
appearance may mimic uterine sarcomas
o Heterologous sarcomatous component
includes chondrosarcoma, osteosarcoma, or
PATHOLOGY rhabdomyosarcoma
General Features
• Etiology CLINICAL ISSUES
o Risk factors similar to endometrial carcinoma,
Presentation
including obesity, exogenous estrogen therapies,
tamoxifen treatment, and nulliparity
▪ Occurs in older, postmenopausal women o Postmenopausal vaginal bleeding
▪ Prior history of pelvic radiation appears to be a • Other signs/symptoms
strong risk factor o Pelvic pain, vaginal discharge
o Comprise of 2-3% of all uterine malignancies ▪ Mass protruding through endocervical canal
▪ Account for 40-50% of all uterine sarcomas • Clinical profile
• Genetics o Mass protruding through endocervical os is frequent
o Wilms tumor 1 protein and estrogen receptor beta finding at physical examination
(ERBB2) are associated with poor outcomes in uterine o Advanced cases may present with signs secondary to
carcinosarcoma metastases
▪ EGFR, ERBB2, and KIT expression in uterine o CA125 may be elevated
carcinosarcoma ▪ Preoperative CA125 elevation is a marker of
• Associated abnormalities extrauterine disease and deep myometrial invasion
▪ Postoperative CA125 monitoring may be useful in
o Pelvic lymphadenopathy, distant lung and liver
metastases detecting tumor recurrence
Demographics
• Age
o More common in postmenopausal women
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Uterus
• Epidemiology 11. Wu YC et al: Intramural metastases of rectum from
o Uncommon tumors representing < 2-3% of all carcinosarcoma (malignant müllerian mixed tumor) of
uterine cervix. Clin Nucl Med. 38(2):137-9, 2013
malignant uterine tumors
o Most common uterine sarcoma 12. Lee EJ et al: Malignant mixed Müllerian tumors of the
uterus: sonographic spectrum. Ultrasound Obstet Gynecol.
▪ Accounts for nearly 50% of uterine sarcomas 39(3):348-53, 2012
Natural History & Prognosis 13. Shah SH et al: Uterine sarcomas: then and now. AJR Am J
• Poor prognosis, with early development of metastases Roentgenol. 199(1):213-23, 2012
• Most important prognostic factors

14. Tropé CG et al: Diagnosis and treatment of sarcoma of the
uterus. A review. Acta Oncol. 51(6):694-705, 2012
o Stage of disease 15. Genever AV et al: Can MRI predict the diagnosis of
o Advanced age endometrial carcinosarcoma? Clin Radiol. 66(7):621-4, 2011
o Depth of myometrial invasion 16. Bharwani N et al: MRI appearances of uterine malignant
o Presence of residual tumor after primary surgery mixed müllerian tumors. AJR Am J Roentgenol.
o Postoperative CA125 elevation is an independent
195(5):1268-75, 2010
17. Kato H et al: Carcinosarcoma of the uterus: radiologic-
prognostic factor for poor survival pathologic correlations with magnetic resonance imaging
Treatment including diffusion-weighted imaging. Magn Reson
• Surgery: Total abdominal hysterectomy and bilateral Imaging. 26(10):1446-50, 2008

18. Spaziani E et al: Carcinosarcoma of the uterus: a case
salpingo-oophorectomy, pelvic and paraaortic report and review of the literature. Eur J Gynaecol Oncol.
lymphadenectomy 29(5):531-4, 2008
• Preoperative and postoperative radiation treatment, 19. Tanaka YO et al: Carcinosarcoma of the uterus: MR findings.
chemotherapy J Magn Reson Imaging. 28(2):434-9, 2008
o Postoperative adjuvant pelvic radiotherapy decreases 20. Teo SY et al: Primary malignant mixed mullerian tumor of
rate of pelvic recurrences but does not improve the uterus: findings on sonography, CT, and gadolinium-
survival enhanced MRI. AJR Am J Roentgenol. 191(1):278-83, 2008
21. Huang GS et al: Serum CA125 predicts extrauterine disease
and survival in uterine carcinosarcoma. Gynecol Oncol.
DIAGNOSTIC CHECKLIST 107(3):513-7, 2007
22. Takeuchi M et al: Pathologies of the uterine endometrial
Consider cavity: usual and unusual manifestations and pitfalls on
• MR for evaluation of large uterine masses magnetic resonance imaging. Eur Radiol. 15(11):2244-55,
2005
Image Interpretation Pearls 23. Callister M et al: Malignant mixed Mullerian tumors of the
• Any uterine sarcoma could appear as large, uterus: analysis of patterns of failure, prognostic factors,
and treatment outcome. Int J Radiat Oncol Biol Phys.
heterogeneous, and aggressive mass in uterus
58(3):786-96, 2004
24. Chaudhry S et al: Benign and malignant diseases of the
SELECTED REFERENCES endometrium. Top Magn Reson Imaging. 14(4):339-57,
2003
1. Jantarasaengaram S et al: Three-dimensional ultrasound 25. Kido A et al: Diffusely enlarged uterus: evaluation with MR
with volume contrast imaging for preoperative assessment imaging. Radiographics. 23(6):1423-39, 2003
of myometrial invasion and cervical involvement in women 26. Rha SE et al: CT and MRI of uterine sarcomas and their
with endometrial cancer. Ultrasound Obstet Gynecol. mimickers. AJR Am J Roentgenol. 181(5):1369-74, 2003
43(5):569-74, 2014 27. Szklaruk J et al: MR imaging of common and uncommon
2. Anupama R et al: Carcinosarcoma of the uterus-a single large pelvic masses. Radiographics. 23(2):403-24, 2003
institution retrospective analysis of the management and 28. Inthasorn P et al: Analysis of clinicopathologic factors in
outcome and a brief review of literature. Indian J Surg malignant mixed Mullerian tumors of the uterine corpus.
Oncol. 4(3):222-8, 2013 Int J Gynecol Cancer. 12(4):348-53, 2002
3. Guntupalli SR et al: Wilms' tumor 1 protein and estrogen 29. Ohguri T et al: MRI findings including gadolinium-
receptor beta expression are associated with poor outcomes enhanced dynamic studies of malignant, mixed
in uterine carcinosarcoma. Ann Surg Oncol. 20(7):2373-9, mesodermal tumors of the uterus: differentiation from
2013 endometrial carcinomas. Eur Radiol. 12(11):2737-42, 2002
4. Lopez-Chardi L et al: Mesonephric carcinosarcoma of 30. Sahdev A et al: MR imaging of uterine sarcomas. AJR Am J
the uterine cervix: a case report. Eur J Gynaecol Oncol. Roentgenol. 177(6):1307-11, 2001
34(4):336-8, 2013
5. Machida H et al: Impact of multimodal therapy on
the survival of patients with newly diagnosed uterine
carcinosarcoma. Eur J Gynaecol Oncol. 34(4):291-5, 2013
6. Pacaut C et al: Uterine and ovary carcinosarcomas: outcome,
prognosis factors, and adjuvant therapy. Am J Clin Oncol.
Epub ahead of print, 2013
7. Rauh-Hain JA et al: Prognostic determinants in patients
with uterine and ovarian carcinosarcoma. J Reprod Med.
58(7-8):297-304, 2013
8. Saglam O et al: AKT, EGFR, C-ErbB-2, and C-kit expression
in uterine carcinosarcoma. Int J Gynecol Pathol.
32(5):493-500, 2013
9. Sutton G: Uterine sarcomas 2013. Gynecol Oncol.
130(1):3-5, 2013
10. Tasic L et al: Carcinosarcoma of the uterus in advanced
stage: a case report. Eur J Gynaecol Oncol. 34(4):343-6, 2013 2
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in a patient with surgically
proven MMMT shows a
large, polypoid, intracavitary
uterine mass expanding
the endometrial cavity
and prolapsing into the
endocervical canal . Note
the frond-like appearance
of the polypoid mass .
(Right) Sagittal T1WI C+
FS MR in the same patient
shows enhancement of the
polypoid MMMT that is
involving the lower uterine
segment and prolapsing into
the endocervical canal .
(Left) Sagittal T1 C+ SPGR MIP

MR in a patient with surgically
proven MMMT shows a
bulky polypoid intracavitary
mass with invasion of
the myometrium . (Right)
Coronal T2WI FSE MR shows
the relative T2-hyperintense
mass replacing the entire
uterine endometrial cavity
and myometrium in this
patient with MMMT.
(Left) Axial T1WI C+ FS MR of

the pelvis shows an enhancing
mass replacing the uterus .
a malignant mixed mesodermal
tumor. (Right) Axial diffusion-
weighted image in the same
patient demonstrates avid
diffusion restriction of the
large pelvic mass, surgically
proven to be a malignant
mixed mesodermal tumor
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Uterus
ultrasound image in a 74-year-
old patient who presented with
vaginal bleed shows a large,
echogenic mass replacing
the endometrial cavity and
invading the myometrial cavity
. Note the mass prolapsing
into the endocervical canal .
(Right) Axial CECT centered in
the pelvis demonstrates a large
expansile intracavitary mass
replacing the endometrial cavity
with frond-like soft tissue .
Surgical pathology confirmed
MMMT.
(Left) Axial CECT lower down

polypoid mass expanding the the
endometrial cavity . (Right)
Axial T1WI C+ FS MR in a patient
with surgically proven malignant
mixed mesodermal tumor shows
a heterogeneous mass replacing
the endometrial cavity and
invading the uterine myometrium
.
(Left) Axial T1WI C+ FS

MR of the pelvis shows a
mass with regions of necrosis
and soft tissue
replacing the uterus. There is
associated necrotic external iliac
adenopathy in this patient,
surgically proven to be MMMT.
(Right) Axial T2WI FSE MR in
the same patient lower down
shows the large MMMT mass
canal , replacing the uterine
cavity and myometrium. Note
the associated pelvic adenopathy
.
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Uterus UTERINE LEIOMYOSARCOMA
Key Facts
Terminology • Role of imaging is to define local extent and distant
• Malignant smooth muscle tumor of uterus arising metastases of disease for treatment planning
• MR is method of choice for assessment of local extent
from myometrial tissue or smooth muscle of
myometrial vessels of tumor due to its superior soft tissue resolution
• MR may be helpful to differentiate leiomyomas from
Imaging leiomyosarcomas
• Solitary, heterogeneous, often large, poorly Clinical Issues
demarcated, intramural mass with areas of hemorrhage
and necrosis • Vaginal bleeding
• Areas of necrosis do not enhance and often • Growing pelvic mass
demonstrate irregular margins • Accounts for 15-40% of all uterine sarcomas
• Areas of hemorrhage demonstrate high T1 signal • Surgery: Total abdominal hysterectomy (TAH) and
intensity bilateral salpingo-oophorectomy (BSO)
• Necrotic areas in mass demonstrate high T2 signal • Adjuvant chemotherapy
intensity
• Demonstrate marked diffusion restriction at DWI Diagnostic Checklist
• Shows avid FDG-18 uptake in primary tumor and • Leiomyosarcoma may be confused with leiomyoma
metastatic foci on imaging, but rapid increase in size of mass suggests
leiomyosarcoma
(Left) Axial T1WI C+

FS MR in a 67-year-old
woman who presented with
shows a large enhancing
pelvic mass with regions of
central necrosis . Surgical
resection proved to be a
leiomyosarcoma of the uterus.
the heterogeneous enhancing
uterine mass with central
necrosis , proven to be a
high-grade leiomyosarcoma
(Left) Axial T2WI FSE MR in

a 71-year-old woman who
presented with pelvic mass
shows a heterogeneous pelvic
mass with internal regions
of hyperintense T2 signal
corresponding to foci of
necrosis. Surgical pathology
confirmed leiomyosarcoma.
(Right) Coronal T2WI FSE
MR in the same patient with
uterine leiomyosarcoma shows
the extent of the large uterine
mass .
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UTERINE LEIOMYOSARCOMA
Uterus
o Leiomyosarcoma may be indistinguishable from
TERMINOLOGY
leiomyoma on US
Definitions o US is limited in evaluation of local extent of disease,
• Malignant smooth muscle tumor of uterus arising from especially when mass is large
myometrial tissue or smooth muscle of myometrial • Color Doppler
vessels o Shows increased vascularity in leiomyosarcomas
unlike benign leiomyomas
IMAGING • Power Doppler
o More sensitive to detect tumor vascularity
General Features Nuclear Medicine Findings
• Best diagnostic clue • PET
o Solitary, heterogeneous, poorly demarcated,
o Shows avid FDG-18 uptake in primary tumor and
intramural mass with areas of hemorrhage and
metastatic foci
necrosis
▪ Rapidly growing pelvic mass Imaging Recommendations
• Location • Best imaging tool
o Myometrium, but large masses could extend into o Role of imaging is to define local extent and distant
adjacent pelvic structures metastases of disease for treatment planning
• Size o MR is method of choice for assessment of local extent
o Often large (6-10 cm) of tumor due to its superior soft tissue resolution
• Morphology o MR may be helpful to differentiate leiomyomas from
o Well-defined or ill-defined heterogeneous masses leiomyosarcomas
resulting in uterine enlargement o CT is helpful in assessment of extent of adjacent
organ invasion and distant metastases
CT Findings • Protocol advice
• NECT o T1WI: Entire pelvis with large field of view
o Difficult to differentiate mass from normal uterus o T2WI: Transverse, sagittal, and coronal planes with
o Areas of hemorrhage may appear as high-attenuation
small field of view
regions within mass o T1 C+: Dynamic post-contrast images in sagittal
o Areas of necrosis are seen as low-attenuation regions
plane
within mass ▪ Diffusion-weighted imaging may also be helpful to
• CECT differentiate leiomyomas from leiomyosarcoma
o Heterogeneously enhancing, low-attenuation mass
relative to homogeneously enhancing myometrium
o Areas of necrosis do not enhance and often DIFFERENTIAL DIAGNOSIS
demonstrate irregular margins Leiomyoma
o Uterus is often enlarged by mass
▪ Metastases to lung and liver • Homogeneously low signal intensity on T2WI
• Degenerated leiomyomas have heterogeneous
MR Findings appearance and may be confused with leiomyosarcoma
• T1WI • Absence of metastasis is an important clue in
o Low or intermediate signal intensity mass differential diagnosis
o Areas of hemorrhage demonstrate high T1 signal
Adenomyosis
•
intensity
T2WI
• Adenomyosis infiltrates myometrium without
displacing endometrium
o Intermediate signal intensity heterogeneous mass
• Junctional zone is thickened in adenomyosis
relative to myometrium
o Necrotic areas in mass demonstrate high T2 signal • Heterotopic endometrial tissue in adenomyosis has
characteristic appearance of hyperechoic foci on US
intensity and hyperintense foci on T2WI MR
o Uterus is often enlarged by mass
• DWI Endometrial Cancer
o Demonstrate marked diffusion restriction • Located in endometrial cavity but may invade into
• T1WI C+ myometrium
o Heterogeneous enhancement • Leiomyosarcomas are located in myometrium
o Less enhancement compared to normal and often displace endometrial cavity rather than
myometrium, which enhances homogeneously expanding it
o Areas of necrosis do not enhance and often
Other Uterine Sarcomas
demonstrate irregular margins
• Any of the uterine sarcomas could appear as a large,
Ultrasonographic Findings heterogeneous, and aggressive mass in uterus
• Grayscale ultrasound • Difficult to differentiate different types of uterine
o Heterogeneous echogenicity in mass due to solid, sarcomas based on imaging
necrotic, &/or hemorrhagic regions
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Uterus UTERINE LEIOMYOSARCOMA
PATHOLOGY DIAGNOSTIC CHECKLIST

General Features Consider
• Arise from myometrium itself or smooth muscle of • MR for evaluation of large uterine masses
myometrial vessels
• Large size of tumor at presentation (6-10 cm) Image Interpretation Pearls
• Spread: Local extension, peritoneal implantation, • Leiomyosarcoma may be confused with leiomyoma
lymphatic or hematogenous spread on imaging, but rapid increase in size of mass suggests
• Distant metastases: Lung, liver, brain, bone •
leiomyosarcoma
Any of the uterine sarcomas could appear as large,
Staging, Grading, & Classification heterogeneous, and aggressive mass in uterus
• According to modification of FIGO staging system for
endometrial cancer SELECTED REFERENCES
o Stage I: Tumor is confined to uterine corpus
o Stage II: Tumor involves corpus and cervix 1. Sato K et al: Clinical application of diffusion-weighted
o Stage III: Spread outside uterus but confined to pelvis imaging for preoperative differentiation between uterine
o Stage IV: Spread outside true pelvis or into mucosa of leiomyoma and leiomyosarcoma. Am J Obstet Gynecol.
210(4):368, 2014
bladder or rectum 2. Tirumani SH et al: Current concepts in the imaging of
Gross Pathologic & Surgical Features uterine sarcoma. Abdom Imaging. 38(2):397-411, 2013
• Soft fleshy tumors containing areas of hemorrhage and 3. Shah SH et al: Uterine sarcomas: then and now. AJR Am J
Roentgenol. 199(1):213-23, 2012
necrosis 4. Tropé CG et al: Diagnosis and treatment of sarcoma of the
Microscopic Features uterus. A review. Acta Oncol. 51(6):694-705, 2012
• Pleomorphic spindle-shaped muscle cells with 5. Qiu LL et al: Sarcomas of abdominal organs: computed
tomography and magnetic resonance imaging findings.
hyperchromatic nuclei, high number of abnormal Semin Ultrasound CT MR. 32(5):405-21, 2011
mitoses 6. Wu TI et al: Clinical presentation and diagnosis of uterine
• Irregular and extensive invasion to myometrium sarcoma, including imaging. Best Pract Res Clin Obstet
Gynaecol. 25(6):681-9, 2011
7. Cornfeld D et al: MRI appearance of mesenchymal tumors of
CLINICAL ISSUES the uterus. Eur J Radiol. 74(1):241-9, 2010
8. Amant F et al: Clinical management of uterine sarcomas.
Presentation Lancet Oncol. 10(12):1188-98, 2009
• Most common signs/symptoms 9. Fukunishi H et al: Unsuspected uterine leiomyosarcoma:
o Pelvic pain magnetic resonance imaging findings before and after
o Vaginal bleeding focused ultrasound surgery. Int J Gynecol Cancer.
▪ Growing pelvic mass 17(3):724-8, 2007
10. Wu TI et al: Prognostic factors and impact of adjuvant
chemotherapy for uterine leiomyosarcoma. Gynecol Oncol.
o Advanced cases may present with symptoms related 100(1):166-72, 2006
to metastases 11. Acharya S et al: Rare uterine cancers. Lancet Oncol.
• Clinical profile 6(12):961-71, 2005
o Rapidly enlarging pelvic mass 12. Livi L et al: Treatment of uterine sarcoma at the Royal
Marsden Hospital from 1974 to 1998. Clin Oncol (R Coll
Demographics Radiol). 16(4):261-8, 2004
• Age 13. Tanaka YO et al: Smooth muscle tumors of uncertain
malignant potential and leiomyosarcomas of the uterus: MR
o Most commonly affects women in 5th decade
•
findings. J Magn Reson Imaging. 20(6):998-1007, 2004
Epidemiology 14. Cantisani V et al: Vaginal metastasis from uterine
o Rare uterine tumor (< 1%) leiomyosarcoma. Magnetic resonance imaging features
o Accounts for 15-40% of all uterine sarcomas with pathological correlation. J Comput Assist Tomogr.
27(5):805-9, 2003
Natural History & Prognosis 15. Kido A et al: Diffusely enlarged uterus: evaluation with MR
• Favorable prognostic factors imaging. Radiographics. 23(6):1423-39, 2003
o Early stage 16. Rha SE et al: CT and MRI of uterine sarcomas and their
o Low grade mimickers. AJR Am J Roentgenol. 181(5):1369-74, 2003
o Premenopausal age 17. Szklaruk J et al: MR imaging of common and uncommon
o Size < 5 cm large pelvic masses. Radiographics. 23(2):403-24, 2003
•
18. Goto A et al: Usefulness of Gd-DTPA contrast-enhanced
5-year overall survival ranges from 50-65% dynamic MRI and serum determination of LDH and its
• Recurrences in 45-73% of patients isozymes in the differential diagnosis of leiomyosarcoma
from degenerated leiomyoma of the uterus. Int J Gynecol
Treatment Cancer. 12(4):354-61, 2002
• Surgery: Total abdominal hysterectomy (TAH) and 19. Ohara N. Related Articles et al: A comparison of MRI
bilateral salpingo-oophorectomy (BSO) findings of uterine leiomyosarcoma before surgery and at
• Adjuvant chemotherapy recurrence. J Obstet Gynaecol. 22(1):99, 2002
• Adjuvant radiotherapy could reduce local recurrence
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UTERINE LEIOMYOSARCOMA
Uterus
(Left) Axial DWI MR of a patient
with uterine leiomyosarcoma
shows marked diffusion of the
uterine mass. (Right) Axial ADC
image of the same patient with
uterine sarcoma shows marked
diffusion restriction of the
malignant uterine mass.

of the pelvis shows a large,
lobular, enhancing pelvic mass
with linear regions of necrosis
. (Right) Coronal T1WI
C+ FS MR in a patient with
uterine leiomyosarcoma shows
a heterogeneous, enhancing soft
tissue mass arising from the
pelvis.

old woman with a pelvic mass
shows a large, partially necrotic
mass replacing the uterus and
filling the pelvic inlet. Surgical
resection confirmed it to be
high-grade leiomyosarcoma.
patient shows replacement of the
uterus and cervix by the
leiomyosarcomatous tumor.
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Uterus ENDOMETRIAL CARCINOMA
Adapted from 7th edition AJCC Staging Forms.

(T) Primary Tumor for Uterine
Carcinomas
TNM FIGO Definitions
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis¹ Carcinoma in situ (preinvasive carcinoma)
T1 I Tumor confined to corpus uteri
T1a IA Tumor limited to endometrium or invades < 1/2 of myometrium
T1b IB Tumor invades ≥ 1/2 of myometrium
T2 II Tumor invades stromal connective tissue of the cervix but does not extend beyond uterus²
T3a IIIA Tumor invades serosa &/or adnexa (direct extension or metastasis)
T3b IIIB Vaginal involvement (direct extension or metastasis) or parametrial involvement
T4 IVA Tumor invades bladder mucosa &/or bowel mucosa (bullous edema is not sufficient to
classify a tumor as T4)
¹FIGO no longer includes stage 0 (Tis).

²Endocervical glandular involvement only should be considered as stage I and not as stage II.

(N) Regional Lymph Nodes for
Uterine Carcinomas
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 IIIC1 Regional lymph node metastasis to pelvic lymph nodes
N2 IIIC2 Regional lymph node metastasis to paraaortic lymph nodes, ± positive pelvic lymph
nodes

(M) Distant Metastasis for Uterine
Carcinomas
M0 No distant metastasis
M1 IVB Distant metastasis (includes metastasis to inguinal lymph nodes intraperitoneal disease,
or lung, liver, or bone; excludes metastasis to paraaortic lymph nodes, vagina, pelvic
serosa, or adnexa)
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ENDOMETRIAL CARCINOMA
Uterus
AJCC Stages/Prognostic Groups for
Uterine Carcinomas*
Stage T N M
0 Tis N0 M0
I T1 N0 M0
IA T1a N0 M0
IB T1b N0 M0
II T2 N0 M0
III T3 N0 M0
IIIA T3a N0 M0
IIIB T3b N0 M0
IIIC1 T1-T3 N1 M0
IIIC2 T1-T3 N2 M0
IVA T4 Any N M0
IVB Any T Any N M1
*Carcinosarcomas should be staged as carcinoma.
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Stage IA-IB (T1a-T1b N0 M0) Stage II (T2 N0 M0)
Coronal graphic shows T1 tumors, those confined to the corpus Coronal graphic shows a typical T2 tumor , which invades
uteri. T1a tumors are limited to the endometrium or involve the cervix but does not extend beyond the uterus. Endocervical
< 1/2 of the myometrium ; T1b tumors invade 1/2 or more of glandular involvement only should be considered stage I and not
the myometrium indicated by the tumor traversing the dotted stage II.
horizontal line, marking the halfway plane of the myometrium.
Stage IIIA-B (T3a-T3b N0 M0) Stage IVA (T4 N0 M0)
Coronal graphic shows stage III disease, both T3a, which is tumor Sagittal graphic shows stage IVA disease with tumor that invades
involving the serosa &/or adnexa , and T3b, which is tumor the bladder mucosa &/or bowel mucosa . However, bullous
that involves the vagina by direct extension or metastases or edema is not sufficient to classify a tumor as T4. Stage IVB is
parametrial involvement. defined as distant metastasis, including metastasis to inguinal lymph
nodes, peritoneum, lung, liver, or bone.
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Uterus
N1 N2
Coronal graphic shows an example of N1 disease, defined as Coronal graphic shows an example of N2 disease, defined as
regional lymph node metastasis to pelvic lymph nodes . regional lymph node metastasis to paraaortic lymph nodes ±
positive pelvic lymph nodes .
METASTASES, ORGAN FREQUENCY

Lung 32%
Liver 7%
Other sites (adrenal 4%
gland, breast, brain, bone,
skin)
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o Bone
OVERVIEW o Skin
o Brain (uncommon)
General Comments
• Peritoneal spread
• Defined as cancers above level of cervical os involving o Intraperitoneal implants
upper 2/3 of uterus o Malignant ascites
• Corpus uteri carcinoma is most common gynecologic o High-grade endometrioid, clear cell, serous papillary
cancer in USA
subtypes have propensity to spread along serosal and
• 95% of uterine malignancies are endometrial peritoneal surfaces
carcinomas
Classification General Features
• Comments
• Endometrial carcinoma (WHO classification) o Endometrial cancer can be divided into 2 types
o Endometrioid adenocarcinoma
o ▪ Type I
Mucinous adenocarcinoma
o – Endometrioid histology
Serous adenocarcinoma
o – Includes very common endometrioid
Clear cell adenocarcinoma
o adenocarcinoma
Mixed cell adenocarcinoma
o – Up to 70-80% of new diagnoses in USA
Squamous cell carcinoma
o – Association with chronic estrogen exposure
Transitional cell carcinoma
o – Premalignant disease, such as endometrial
Small cell carcinoma
o hyperplasia, often precedes cancer
Others
▪ Type II
– Nonendometrioid histology
– Includes papillary serous and clear cell
PATHOLOGY carcinomas
– Aggressive clinical course
Routes of Spread – No association with estrogen exposure has been
• Direct extension identified
o Most common
o Tumor invades myometrium, cervix, parametria, – Not associated with readily observable
premalignant disease
adnexa, vagina, urinary bladder, and rectum
• Genetics
• Lymphatic spread o Rare hereditary form
o Regional lymph nodes
▪ Lynch II family cancer syndrome
▪ Pelvic nodes (N1)
– Nonpolyposis colorectal cancer
▪ Paraaortic nodes (N2)
o Distant metastases (M1) – Ovarian cancer
– Endometrial cancer
▪ Nodes above level of renal veins o Type I endometrial cancers
▪ Inguinal nodes
▪ Microsatellite instability
▪ Supraclavicular nodes
o Nodal metastases may skip ▪ KRAS mutations
▪ PTEN mutations
▪ Tumor spreads through ovarian lymphatics to
▪ DNA mismatch repair defects
paraaortic without pelvic adenopathy
o Anatomic criteria for defining lymph nodes as ▪ Mutations in p53
– Less frequent
pathologic
– Late occurrence in development (differing from
▪ Oval nodes ≥ 1 cm in short axis
type II cancers)
▪ Round nodes ≥ 0.8 cm in diameter o Type II endometrial cancers
▪ Central necrosis ▪ Mutations in p53
▪ Enhancement of nodes or node signal is not – Common mutation
predictive of metastatic lymphadenopathy ▪ Nondiploid karyotype
▪ CT and MR have 60-90% accuracy in assessing ▪ ERBB2 (Her-2/neu) overexpression
involvement of pelvic and paraaortic lymph nodes
o Metabolic criteria for defining lymph nodes as
• Etiology
o Carcinoma that spontaneously arises from
pathologic endometrium that is atrophic or inert
▪ High positive predictive value when nodes 7-15 o Risk factors
mm demonstrate increased metabolic activity ▪ Estrogen hormone replacement therapy (2-10x)
▪ Insensitive for small nodal metastases < 6-7 mm ▪ Obesity (2-20x)
– Below resolution of most PET cameras ▪ Polycystic ovarian syndrome (PCOS) (3x)
▪ Increased sensitivity for nodal metastases with ▪ Chronic anovulation (3x)
FDG-18 PET ▪ Tamoxifen (2-3x)
o Increased sensitivity for nodal metastases with MR
▪ Nulliparity (2-3x)
enhanced by ultrasmall superparamagnetic iron ▪ Early menarche (2-3x)
oxide (USPIO) ▪ Late menopause (2-3x)
• Hematogenous spread ▪ Hypertension (2-3x)
o Lungs
▪ Diabetes (2-3x)
2 o Liver
• Epidemiology & cancer incidence
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o Estimated 2014 statistics in USA • Ultrasound
▪ 52,630 new cases o Polypoid mass or diffuse endometrial thickening
▪ 8,590 deaths ▪ Thickened endometrial complex
o Represents 6% of all cancers in women – Hyperechoic with well-defined borders
o Most common gynecologic malignancy in – ± areas of decreased echogenicity within
industrialized nations thickened endometrium
• Associated diseases, abnormalities ▪ Mass-like lesion may be heterogeneous or
o 20-40% associated with endometrial hyperplasia homogeneous
▪ Subendometrial halo
Microscopic Pathology – May be intact
• H&E – May have focal or diffuse disruption
o Histological patterns can be broadly divided into
– Disruption suggestive of myometrial invasion
type I and type II endometrial cancers o Pulsed Doppler
▪ Endometrioid histology ▪ Benign and malignant thickening of endometrium
▪ Nonendometrioid histology show significant overlap in resistive index and
o Histopathologic types
pulsatility
▪ Endometrioid carcinomas o Color Doppler
– Most common endometrial cancer (75-80% of ▪ Mild to moderate vascularity with multiple feeding
cases) vessels
– Most are well differentiated o 3D ultrasound
– Back-to-back glandular proliferation of ▪ May offer superior endometrial cancer volume
endometrium lacking intervening stroma measurement as compared to thickness
▪ Villoglandular adenocarcinoma measurement in detecting endometrial cancer
– Many villous fronds o Limited evaluation of cervix, parametria, and lymph
– Delicate central fibrovascular cores of villi and nodes
simpler branching pattern differentiates it from • CT
papillary serous carcinoma o NECT
▪ Adenocarcinoma with benign squamous elements, ▪ Difficult to differentiate between cancer and
squamous metaplasia, or squamous differentiation normal uterine tissue
(adenoacanthoma) o CECT
▪ Adenosquamous carcinoma (mixed ▪ Diffuse endometrial thickening or discrete mass
adenocarcinoma and squamous cell carcinoma) may be visualized in uterine cavity
▪ Mucinous adenocarcinoma ▪ Tumor is typically hypodense to myometrium
▪ Serous adenocarcinoma (papillary serous) ▪ Mass located centrally
– Bizarre nuclei ▪ Myometrial invasion is indicated by irregular
– Scant cytoplasm tumor-myometrial interface
– Nuclear stratification • MR
– Marked nuclear atypia o T1WI
– Complex papillary architecture ▪ Tumor is isointense to endometrium and
– Psammoma bodies (seen in 30% of cases) myometrium
– Aggressive nature ▪ Helpful to identify blood in uterine cavity
– Often presents late o T2WI
▪ Clear cell carcinoma ▪ Usually homogeneous
– Possible patterns include tubulocystic, papillary, ▪ Hypointense or isointense relative to endometrium
or solid (100%)
– Psammoma bodies may be present but not as ▪ Isointense or hyperintense relative to outer
commonly as in papillary serous tumors myometrium (70%)
– Clear cell appearance due to glycogen o T1WI C+
– Myometrial invasion is common (80% of ▪ Homogeneous enhancement
carcinomas) ▪ Dynamic contrast enhanced (DCE)
– Aggressive nature – Tumor enhances earlier than normal
– Often presents late endometrium
▪ Squamous cell carcinoma – Tumor enhances more slowly than myometrium
▪ Undifferentiated carcinoma – Tumor is less avidly enhancing relative to
▪ Malignant mixed mesodermal tumors myometrium and cervix
– Subendometrial enhancement is best seen early
– Maximum tumor-to-myometrium contrast at
IMAGING FINDINGS 50-120 seconds post contrast
▪ Subtraction images
Detection – Valuable in differentiating enhancement from
• General features intrinsic high signal (tumor from blood)
o Localized or diffuse tumors o DWI
▪ Polypoid mass superficially attached to ▪ Lower ADC (increased water restriction) in tumor
endometrium resulting in uterine cavity expansion
▪ Diffuse endometrial thickening
relative to normal endometrium and myometrium
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▪ Improves tumor detection and delineation from ▪ Sequences helpful for evaluation of depth of
surrounding tissues myometrial invasion
– Small cervical or vaginal implants – High-resolution small FOV T2 FSE in sagittal and
– Small serosal or peritoneal deposits axial oblique (uterine short axis) planes
▪ Studies indicate better performance than DCE MR – Dynamic T1WI C+ FS in sagittal plane at 25 sec, 1
for determination of depth of myometrial invasion min, 2 min, and in axial oblique plane at 4 min
▪ ADC values are unable to differentiate low-grade – DWI (at least 2 b values) in sagittal and axial
from high-grade tumors oblique planes
▪ Limitations ▪ Perform 1 large FOV sequence (T1 or T2) of
– Possible false-positive with secretory or abdomen and pelvis to assess for adenopathy and
hyperplastic endometrium hydronephrosis
– Blood products have low ADC (must interpret in
conjunction with T1WI) Staging
– Well-differentiated adenocarcinoma may have • General comments
o 75% have disease confined to uterus
low cellularity and high ADC
– Necrotic tumors may have high ADC o Complete FIGO staging
– Retained mucus in obstructed endometrial ▪ Total abdominal hysterectomy
cavity may have restricted diffusion ▪ Bilateral salpingo-oophorectomy
– Cannot differentiate benign and malignant ▪ Peritoneal washings
lymph nodes ▪ Retroperitoneal lymph node dissection
o Advantages of MR o Effect of positive peritoneal cytology on outcome
▪ Young patients desiring fertility-sparing treatment is unclear and therefore currently not included in
– Exclude myometrial invasion before treatment staging
o Imaging not including in FIGO staging, but can be
with hormonal therapy
▪ Neoadjuvant radiation therapy planning in helpful for surgical planning
nonsurgical candidates ▪ MR is best for staging local tumor extent
▪ Determine endometrial or cervical origin of ▪ CT and PET/CT are best for adenopathy and
adenocarcinoma when biopsy is inconclusive extrauterine spread
▪ Predict high-risk surgical cases to be performed by o Risk stratification based on imaging and endometrial
subspecialized gynecologic oncologist biopsy
• PET ▪ Low risk
o FDG-18 PET valuable in detection of lymph node and – Grade 1 and 2 endometrioid tumors and < 50%
distant metastases and surveillance for recurrence myometrial invasion
o Metastatic lesions may have variable FDG activity ▪ Intermediate risk
compared to FDG activity of primary tumor – Grade 3 endometrioid tumor and < 50%
o Moderate sensitivity of 63% for metastatic myometrial invasion
adenopathy (specificity 95%) – Grade 1 and 2 endometrioid tumors and ≥ 50%
▪ Improved sensitivity with larger lymph node size myometrial invasion
– 16.7% for nodes < 4 mm ▪ High risk
– 66.7% for nodes 5-9 mm – Grade 3 endometrioid tumors and ≥ 50%
– 93.3% for nodes > 10 mm myometrial invasion
o Limitations – Type 2 histologic subtype (clear cell and
▪ Not helpful for primary tumor staging and papillary serous) and any stage
assessing myometrial or cervical involvement o Incidence of metastatic adenopathy
▪ Unable to detect micrometastases ▪ Low risk: < 5% risk of nodal disease
▪ Low-grade tumors ▪ Intermediate risk: 5-9% pelvic, 4% paraaortic
▪ Serous or mucinous tumors ▪ High risk: 20-60% pelvic, 10-30% paraaortic
• Recommendations • Ultrasound
o Best imaging tool o Greatest accuracy in early stage disease with small
▪ TVUS can be used in initial evaluation, particularly tumors
in cases of abnormal bleeding o Overstaging can be seen in large, polypoid lesions
– Most common modality for detection • CECT
– Endometrial sampling should be performed in o Local staging limited due to lack of accurate
presentation of postmenopausal bleeding with demonstration of deep myometrial invasion and
endometrial complex > 5 mm cervical involvement
▪ MR for tumor stage and treatment planning o Lack of zonal anatomy results in decreased accuracy
o MR protocol advice (65-75%)
▪ Decrease artifact from small bowel and uterine o Frequently used modality in assessing
peristalsis lymphadenopathy and distant metastases
– Fast 4-6 hours prior to exam • MR
– Administer antiperistaltic agent o Most accurate imaging modality for local staging
▪ Void 30-60 min prior to exam as full bladder may ▪ 80-90% overall accuracy
degrade T2WI o Limitations in accurate assessment of myometrial
2 invasion
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▪ Myometrial thinning and loss of zonal anatomy in o Vaginal or parametrial involvement
postmenopausal women o Can be by direct extension or metastasis
▪ Peritumoral inflammation leading to o Parametrial invasion impacts surgery requiring
overestimation of depth of myometrial invasion on radical hysterectomy
postcontrast images o T2WI
▪ Distortion of normal uterine anatomy by ▪ Invasion of normal low SI vaginal wall by
coexisting leiomyomas and adenomyosis intermediate/high SI tumor
▪ Tumor extension into cornua • Stage IIIC1
▪ Myometrial compression by large polypoid tumor o Primary tumor stage T1-T3 with regional adenopathy
• Stage IA to pelvic nodes
o Tumor limited to endometrium or invades < 1/2 of o CT and MR have 60-90% accuracy in detecting
myometrium adenopathy
o T1WI C+ and DWI are particularly helpful to • Stage IIIC2
determine depth of myometrial invasion o Primary tumor stage T1-T3 with regional adenopathy
o Irregular endometrium/myometrium interface is to paraaortic nodes
suggestive of myometrial invasion o May or may not have pelvic adenopathy
o Intact junctional zone on T2WI and preservation of • Stage IVA
smooth rim of early subendometrial enhancement o Tumor invades urinary bladder or bowel mucosa
post contrast excludes deep myometrial invasion o T2WI
• Stage IB ▪ Tumor disrupts low SI bladder/bowel wall with
o Tumor invades ≥ 1/2 of myometrium mucosal invasion
o Disruption or irregularity of junctional zone and o Bullous edema
subendometrial enhancement ▪ Reactive mucosal edema due to invasion of
o Preserved rim of avidly enhancing myometrium subserosal or muscle layers of urinary bladder
o MR is best modality for assessing depth of ▪ Does not qualify as stage IVA due to absence of
myometrial invasion mucosal invasion by tumor
▪ 70-95% sensitivity • Stage IVB
▪ 80-95% specificity o Distant metastatic disease (beyond true pelvis)
▪ 82% accuracy ▪ Inguinal or upper abdominal (above renal veins)
• Stage II adenopathy
o Tumor invades cervical stroma, but remains confined ▪ Peritoneal deposits
to uterus ▪ Malignant ascites
o Does not include cervical mucosal invasion or tumor ▪ Lung, liver, bone
extension into and expansion of endocervical canal o Metastatic disease is rare at presentation
o Cervical stromal invasion is rare without epithelial
invasion
Restaging
o MR is best for assessment of cervical involvement • 15% develop recurrent disease
o 87% of recurrences occur within 3 years
▪ T2WI
o 46% to lymph nodes
– Intermediate/high signal intensity (SI) tumor
o 42% to vaginal vault (solitary site in 30-50%)
disrupts normal low signal cervical stroma
o Less frequently peritoneal, liver, lung, bone
▪ T1WI C+
– Normal cervical mucosal enhancement excludes • Factors predictive of recurrence
o Advanced stage at presentation
stromal invasion
o Poorly differentiated grade
– 3-4 minute delayed images are useful for
o Tumor ≥ 2 cm at diagnosis
evaluating stromal invasion (normal cervical
o Deep myometrial invasion
stroma enhances later and to lesser degree than
o Cervical stromal invasion
cervical epithelium)
▪ 75-80% sensitivity o Lymphovascular invasion
▪ 94-96% specificity • CT
▪ 90-92% accuracy o Most frequently used modality for restaging patients
o 92% accuracy
• Stage IIIA
o Tumor invades serosa &/or adnexa o Helpful for differentiating scar vs. residual/recurrent
o Can be by direct extension or metastasis tumor
o Adnexal tumor may be present without serosal o More sensitive than PET for detecting early
invasion carcinomatosis or peritoneal spread
o T2WI • PET/CT
▪ Disruption of low SI serosa by intermediate/high SI o Can be helpful for detecting occult disease
o Pitfalls
tumor
▪ Irregular uterine contour ▪ Inability to detect early carcinomatosis and
o T1WI C+ occasionally non-FDG-avid lesions
▪ Loss of rim of avidly enhancing myometrium ▪ Need to look at CT images even if performed at low
o DWI dose to look for peritoneal involvement
▪ May help identify adnexal tumor deposits • Some studies suggest DWI/ADC may be predictive of
• Stage IIIB disease recurrence
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– Bilateral salpingo-oophorectomy
CLINICAL ISSUES – ± LND (unclear benefit, no consensus)
– Adjuvant radiation therapy
Presentation
– Surgery best performed at specialized center
• Most common in 6th and 7th decades of life
▪ Stage II or higher (any grade or histologic subtype)
• > 90% are over age 50
– Radical hysterectomy
• 5% diagnosed before age 40
– Bilateral salpingo-oophorectomy
• Abnormal vaginal bleeding
– Pelvic LND, ± paraaortic LND
o 75-90% present with postmenopausal bleeding
o May also present with leukorrhea ▪ Histologic subtype II: Also perform omentectomy,
pelvic and paraaortic LND, and peritoneal washing
• Other signs and symptoms resulting from metastatic
and biopsy
disease in more advanced cancers may occur o Laparoscopic surgery is feasible and better tolerated,
o Dysuria
o Constipation but contraindicated if peritoneal or extrauterine
o Pain spread
o Radiation therapy (RT)
• Common in Eastern Europe and USA
▪ Adjuvant RT with deep myometrial invasion or
• Uncommon in Asia
grade 3 tumor
Cancer Natural History & Prognosis ▪ No survival advantage in stage 1 disease, but
• Typically diagnosed earlier as majority of women seek decreased locoregional recurrence
evaluation following vaginal bleeding, which is seen in ▪ External beam radiation therapy (EBRT)
most cases ▪ Vaginal cuff brachytherapy
• Majority of patients diagnosed with surgical stage I – Less morbidity, similar results as EBRT for stage 1
disease (70-75% of cases) disease
• Grade 3 endometrioid and histologic type II (clear cell o Recent studies show no advantage to systematic
and papillary serous) tumors lymphadenectomy
o > 50% present with stage IB or higher o No consensus, however lymph node dissection is
o 50% pretest probability of advanced disease or often reserved for high-risk patients
peritoneal spread ▪ Deep myometrial invasion, cervical invasion,
• Prognostic factors poorly differentiated on biopsy
o Histologic grade of tumor o Fertility sparing treatment
▪ Grade at endometrial biopsy is upgraded in 15% on ▪ Preservation of uterus and ovaries
final surgical pathology ▪ D&C for accurate tumor grade
o Depth of myometrial invasion ▪ MR to exclude deep myometrial invasion
▪ Predictor of adenopathy and overall survival ▪ High-dose progestin therapy
o Presence of cervical stromal invasion ▪ Repeat biopsy after 6 months of treatment
▪ Predictor of adenopathy and overall survival ▪ Secondary hysterectomy should be considered
o Lymphovascular space invasion when childbearing completed
▪ Best predictor of nodal involvement and recurrence • Treatment options by stage
o Progesterone receptors o Stage I
▪ Absence of receptors indicates poorer prognosis in ▪ Total hysterectomy (abdominal or laparoscopic)
stage I and II disease and bilateral salpingo-oophorectomy (BSO)
• 5-year survival rates performed if
o Stage I (90%) – Well or moderately differentiated
o Stage II (80%) – Upper 2/3 of corpus is involved
o Stages III and IV (15-20%) – Peritoneal cytology is negative
• 5-year survival rates specific to endometrial – Vascular space invasion not present
adenocarcinoma – < 50% myometrial invasion
o Stage IA (99%) ▪ Sampling of pelvic and selected paraaortic lymph
o Stage IB (99%) nodes
o Stage IC (92%) – If negative, no postop treatment
o Stage II (80%) – If positive, further treatment should be given,
o Stage III (60%) typically involving radiation therapy and
o Stage IV (30%) possibly chemotherapy and surgery
o Stage II
Treatment Options ▪ Documented cervical stromal involvement preop
• Major treatment alternatives – Radical hysterectomy and BSO
o Surgery is primary treatment in most cases – Pelvic and paraaortic lymph node dissection
o Risk stratification determines treatment ▪ Cervical extension found on postop pathology
▪ Low/intermediate risk – Consider radiation treatment
– Simple hysterectomy o Stage III
– Bilateral salpingo-oophorectomy ▪ Generally treated with surgery and radiation
– Lymph node dissection (LND) only if suspicious therapy or chemotherapy or both
nodes on imaging
2 ▪ High risk
– Hysterectomy
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▪ Several randomized trials have shown benefit to 7. Beddy P et al: FIGO staging system for endometrial cancer:
adjuvant chemotherapy instead of radiation if added benefits of MR imaging. Radiographics. 32(1):241-54,
residual tumor is < 2 cm 2012
▪ Inoperable disease may be treated with 8. Koskas M et al: Safety of uterine and/or ovarian preservation
in young women with grade 1 intramucous endometrial
combination chemotherapy and radiation (EBRT adenocarcinoma: a comparison of survival according to the
and brachytherapy) extent of surgery. Fertil Steril. 98(5):1229-35, 2012
▪ Progestational agents may also be considered in 9. Makihara N et al: Large cell neuroendocrine carcinoma
patients who are not candidates for surgery or originating from the uterine endometrium: a report on
radiation therapy magnetic resonance features of 2 cases with very rare and
o Stage IV aggressive tumor. Rare Tumors. 4(3):e37, 2012
▪ Treatment plan guided by sites of metastatic 10. American Joint Committee on Cancer: AJCC Cancer Staging
Manual. 7th ed. New York: Springer. 403-18, 2010
lesions and resulting symptoms
11. Basu S et al: PET and PET-CT imaging of gynecological
▪ When possible treated with cytoreductive surgery malignancies: present role and future promise. Expert Rev
followed by chemotherapy or radiation or both Anticancer Ther. 9(1):75-96, 2009
▪ Bulky pelvic lesions are treated with radiation 12. Bernardini MQ et al: Issues surrounding lymphadenectomy
therapy consisting of intracavity and EBRT in the management of endometrial cancer. J Surg Oncol.
combined 99(4):232-41, 2009
▪ Hormonal therapy is indicated in distant 13. De Gaetano AM et al: Imaging of gynecologic malignancies
metastatic disease, particularly in pulmonary with FDG PET-CT: case examples, physiologic activity, and
pitfalls. Abdom Imaging. 34(6):696-711, 2009
metastases
14. Grigsby PW: Role of PET in gynecologic malignancy. Curr
▪ Progestational agents are most common Opin Oncol. 21(5):420-4, 2009
– Good response in 15-30% 15. Holalkere NS et al: Issues in imaging malignant neoplasms
– Correlates with level of hormone receptors in of the female reproductive system. Curr Probl Diagn Radiol.
tumor and degree of differentiation 38(1):1-16, 2009
16. Peungjesada S et al: Magnetic resonance imaging of
endometrial carcinoma. J Comput Assist Tomogr.
REPORTING CHECKLIST 17.
33(4):601-8, 2009
Whittaker CS et al: Diffusion-weighted MR imaging of
female pelvic tumors: a pictorial review. Radiographics.
T Staging 29(3):759-74; discussion 774-8, 2009
• Depth of myometrium invasion 18. Bakkum-Gamez JN et al: Current issues in the management
• Cervical stromal invasion of endometrial cancer. Mayo Clin Proc. 83(1):97-112, 2008
• Uterine serosal and adnexal invasion 19. Selman TJ et al: A systematic review of tests for lymph
• Vaginal invasion node status in primary endometrial cancer. BMC Womens
• Urinary bladder or rectal mucosal invasion Health. 8:8, 2008
20. Sorosky JI: Endometrial cancer. Obstet Gynecol. 111(2 Pt
N Staging 1):436-47, 2008
• Pelvic adenopathy 21. Akin O et al: Imaging of uterine cancer. Radiol Clin North
• Paraaortic adenopathy Am. 45(1):167-82, 2007
22. Iyer RB et al: PET/CT and cross sectional imaging of
M Staging gynecologic malignancy. Cancer Imaging. 7 Spec No
• Distant adenopathy A:S130-8, 2007
o Inguinal 23. Sala E et al: MRI of malignant neoplasms of the uterine
corpus and cervix. AJR Am J Roentgenol. 188(6):1577-87,
o Abdominal above level of renal veins
2007
• Distant metastases 24. Barwick TD et al: Imaging of endometrial adenocarcinoma.
o Lungs, liver, bone, peritoneum Clin Radiol. 61(7):545-55, 2006
25. Brown MA et al: MR imaging of malignant uterine disease.
Magn Reson Imaging Clin N Am. 14(4):455-69, v-vi, 2006
SELECTED REFERENCES 26. Messiou C et al: MR staging of endometrial carcinoma. Clin
Radiol. 61(10):822-32, 2006
1. American Cancer Society: What are the key statistics 27. Amant F et al: Endometrial cancer. Lancet.
about endometrial cancer? http://www.cancer.org/cancer/ 366(9484):491-505, 2005
endometrialcancer/detailedguide/endometrial-uterine- 28. Ascher SM et al: Imaging of cancer of the endometrium.
cancer-key-statistics. Accessed July 23, 2014 Radiol Clin North Am. 40(3):563-76, 2002
2. National Cancer Institute: Endometrial cancer. http:// 29. Kinkel K et al: Radiologic staging in patients with
www.cancer.gov/cancertopics/types/endometrial. Accessed endometrial cancer: a meta-analysis. Radiology.
July 13, 2014 212(3):711-8, 1999
3. He H et al: MRI is highly specific in determining primary
cervical versus endometrial cancer when biopsy results are
inconclusive. Clin Radiol. 68(11):1107-13, 2013
4. Nougaret S et al: Pearls and pitfalls in MRI of gynecologic
malignancy with diffusion-weighted technique. AJR Am J
Roentgenol. 200(2):261-76, 2013
5. Sala E et al: The added role of MR imaging in treatment
stratification of patients with gynecologic malignancies:
what the radiologist needs to know. Radiology.
266(3):717-40, 2013
6. Wakefield JC et al: New MR techniques in gynecologic
cancer. AJR Am J Roentgenol. 200(2):249-60, 2013 2
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Stage IA (T1a N0 M0) Stage IA (T1a N0 M0)

nonspecific mild thickening
of the endometrium
in this patient with
recently diagnosed stage
IA endometrial carcinoma.
(Right) Axial CECT shows an
enlarged uterus with multiple
leiomyomas and a slightly
prominent endometrium
in this patient with recently
diagnosed endometrial
carcinoma. Pathology
revealed a 2 cm mass that did
not involve the myometrium,
compatible with stage IA.

(Left) Longitudinal
transvaginal grayscale
ultrasound shows a
thickened, heterogeneous
endometrium with
multiple cysts. (Right)
Color Doppler ultrasound
shows areas of increased
color (blood flow) to the
. Pathology revealed
endometrial carcinoma that
had developed within a polyp
in this patient that had been
on tamoxifen. Disease limited
to the endometrium would be
stage IA.

enlarged endometrium
in a patient with recently
carcinoma. Pathology
showed < 50% myometrial
involvement, making this a
T1a lesion and overall stage
IA. (Right) Axial CECT shows
nonspecific endometrial
enlargement and a left
ovarian cyst in this patient
with recently diagnosed stage
IA endometrial carcinoma.
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shows an endometrial mass
with signal characteristics
typical of carcinoma,
hypointense to endometrium
and hyperintense to
myometrium. The junctional
zone appears intact,
thereby excluding deep
myometrial invasion. (Right)
DWI shows the endometrial
mass and junctional
zone allowing confident
diagnosis of stage IA disease.
DWI has been found to
accurately depict depth of
invasion and is particularly
helpful when gadolinium is
contraindicated.

(Left) Sagittal T1WI C+ FS
MR shows enhancement
of the endometrial mass
. The intact rim of early
subendometrial enhancement
excludes deep myometrial
invasion. (Right) Sagittal
T1WI C+ FS MR obtained
later in a dynamic
series of post-contrast
sequences demonstrates
hypoenhancement of
the tumor relative to
myometrium. Subendometrial
enhancement is best seen
early, but maximum tumor-
myometrium contrast occurs
at 2-5 minutes.

(Left) Longitudinal
transvaginal ultrasound does
not clearly demonstrate
the endometrial stripe.
Poor visualization of the
endometrial echo complex in
the setting of vaginal bleeding
is nondiagnostic and should
be further evaluated. (Right)
Sagittal T1WI C+ FS MR in
the same patient shows a
large polypoid endometrial
mass expanding the uterine
cavity with only superficial
< 50% myometrial invasion.
D&C revealed grade 1
endometrial cancer.
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Stage IB (T1b N0 M0) Stage IB (T1b N0 M0)

endometrial mass . (Right)
Sagittal CECT (same patient)
shows the endometrial
mass extending through
endocervical canal and
expanding posterior vaginal
fornix . The surrounding
myometrium appears
intact; however, depth of
invasion is difficult to assess
due to myometrial thinning.
Exam under anesthesia
revealed an effaced but intact
cervix. Pathology showed
grade 3 papillary serous
adenocarcinoma with 60%
myometrial penetration.

enlargement and abnormal
enhancement of the
endometrium . Outside
MR showed involvement
of more than 1/2 of the
myometrial thickness or a T1b
lesion. (Right) Axial CECT
prominence/irregularity of
shown by the low-attenuation
center with heterogeneous
enhancement of the
thickened endometrium/
myometrium . This
patient was diagnosed with

expanded fluid- and debris-
filled endometrial cavity
in this patient with newly
carcinoma. (Right) Axial
shows an enhancing mass
along the right lateral border
of the endometrium and
fluid-filled endometrial cavity
. Pathology showed the
lesion involving almost the full
thickness of the myometrium,
making this a T1b lesion and
overall stage IB.
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irregularly thickened
endometrium with
some fluid/debris in the
endometrial canal in this
patient with postmenopausal
bleeding. (Right) Axial PET/
CT in the same patient shows
intense FDG activity in
compatible with recently
carcinoma. FDG activity
in the endometrium in a
postmenopausal woman
should be further evaluated to
exclude carcinoma.

(Left) Sagittal T1WI C+
MR shows a tumor in a
bulky uterus with multiple
leiomyomas with an
indistinct junctional zone,
raising the suspicion of
myometrial invasion. (Right)
Sagittal T2WI FS MR in the
higher signal mass in a
bulky uterus with a better
view of the multiple low
signal intensity leiomyomas
.

(Left) Axial T1WI C+
FS MR post gadolinium
administration in the same
patient shows that the tumor
involves more than
50% of the myometrium,
making this a T1b lesion or
stage IB. (Right) Cut gross
hysterectomy specimen
from the same patient shows
the presence of stage IB
endometrial cancer . Also
note multiple leiomyomata
.
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Stage II (T2 N0 M0) Stage II (T2 N0 M0)

shows mass-like thickening of
the endometrium invading
the cervical stroma and
obstructing the endocervical
canal. Complex fluid with a
fluid-fluid level fills the
uterus. Depth of myometrial
invasion is difficult to assess
on this image due to thinning
of the myometrium .
MR shows enhancement of
the endometrial mass and
the utility of post-contrast
sequences for assessment of
myometrial invasion. Note the
excellent tumor-myometrial
contrast.

(Left) Transverse color
Doppler transvaginal US
shows a large, irregular mass
along the endometrium
with blood/debris in the
endometrial canal. (Right)
Sagittal T1WI MR in the same
patient shows an endometrial
mass with extension into
the endocervical canal. The
low signal intensity junctional
zone is disrupted anteriorly,
which is compatible with >
50% myometrial extension.
Pathology showed invasion of
cervical stromal tissue.

marked expansion of
with an enhancing mass
compared to normal
uterus in this patient
with recently diagnosed
(Right) Axial PET/CT in the
same patient shows intense
FDG activity correlating
with the bulky endometrial
mass. Although not routinely
used to evaluate the primary
mass, PET/CT can be used
for initial treatment decision
making.
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Stage IIIB (T3b N0 M0) Stage IIIB (T3b N0 M0)
a large, heterogeneously
enhancing mass with an
enlarged uterus in this patient
with recently diagnosed
same patient shows diffuse
intense FDG activity in the
large endometrial mass
occupying the whole uterus.
Involvement of the vagina
makes this a T3b lesion.
FDG activity anteriorly is
normal excretory FDG in the
bladder.
Stage IIIC1 (T3 N1 M0) Stage IIIC1 (T3 N1 M0)

shows a mass surrounding
the proximal common iliac
vessels. The mass shows
abnormally enhancing
wall with central necrosis,
compatible with metastatic
adenopathy. (Right) FDG
PET scan in the same patient
shows abnormal, rim-like,
intense FDG activity
correlating with the mass
surrounding the proximal
common iliac vessels,
compatible with metastatic
adenopathy.
Stage IVA (T4 N0 M0) Stage IVA (T4 N0 M0)

MR shows a large mass
involving the majority of the
endometrium and appearing
to extend into the endocervix
and involve > 50% of the
myometrium. (Right) Sagittal
patient (smaller field of view)
shows the primary mass
with obvious abnormal
enhancement of the posterior
wall of the bladder ,
compatible with a T4 lesion
or stage IVA.
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(Left) Axial T2WI MR
shows the uterus markedly
distended with fluid and
enhancing polypoid tumor
masses . No deep invasion
of the myometrium is evident.
(Right) Axial T1WI C+ MR
the polypoid masses and
irregular enhancing outer
uterine wall indicating
serosal extension.

subtle borderline enlarged
but nonspecific left external
iliac node without any
additional specific features
to suggest malignancy in
this patient with a newly
carcinoma (T4 lesion).
same patient shows mild FDG
activity within the lymph
node . Subsequent follow-
up scan showed interval
enlargement of the node,
compatible with a malignant
node.

(Left) Longitudinal power
Doppler ultrasound
again shows the polypoid
endometrial mass
with increased blood flow
worrisome for endometrial
carcinoma. (Right) Transverse
same patient shows a focal
broad-based mass in the
fundal-posterior region of the
endometrium.
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Stage IVB (T3 N1 M1) Stage IVB (T3 N1 M1)
(Left) Sagittal T2WI FSE
MR shows a hyperintense
mass replacing the uterine
corpus , invading the
upper cervical stroma and
the uterine serosa. There is a
separate hyperintense urethral
mass encasing the Foley
catheter and invading
the urinary bladder base .
external iliac adenopathy
. The urethral metastases
make this stage IVB disease.
Biopsy revealed small cell
Stage IVB (T3a N1 M1) Stage IVB (T4 N1 M1)

(Left) Axial fused PET/CT
shows hypermetabolic
subcarinal adenopathy in
this patient with endometrial
carcinoma invading the
uterine serosa and pelvic
adenopathy. (Right) Axial
CECT shows a mass with
rim enhancement and central
low attenuation (necrosis)
centered along the greater
omentum and invading the
anterior abdominal wall
musculature, compatible with
metastatic disease.
Recurrence Recurrence
(Left) Transverse grayscale
ultrasound shows a nodule
in the thyroid isthmus
with slightly heterogeneous
echotexture in this patient
with a history of metastatic
Although very atypical,
pathology revealed metastatic
(Right) Gross pathology from
solid, yellowish lesion in
the resected thyroid isthmus,
shown to be metastatic
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Uterus ENDOMETRIAL STROMAL SARCOMA
Key Facts
Terminology • High-resolution pelvic MR is modality of choice for
• Malignant mesenchymal tumor of endometrium diagnosis and local staging
• CT can be used in advanced disease with distant spread
Imaging
• Large, heterogeneous, endometrial-based mass with Clinical Issues
• Abnormal vaginal bleeding
predominant myometrial component
• Spread along fallopian tubes, uterine ligaments and • Abdominal pain or mass
gross intravascular extension • 1% of uterine malignancies, 10-25% of primary uterine
• Endometrial thickening/polypoid intrauterine mass sarcomas
• US • Most common between 35-55 years of age
o Heterogeneous, mixed echogenicity endometrial-
based mass, endo- and myometrial thickening, and
adnexal masses • Consider endometrial stromal sarcoma in differential
• DWI
diagnosis of heterogeneous, endometrial-based mass
with significant myometrial component
o Restricts diffusion
• Role of imaging is to suggest diagnosis; define disease
extent for treatment planning

ultrasound of the uterus shows
a large solid echogenic mass
with peripheral vascularity
in a postmenopausal
woman presenting with
vaginal bleeding. (Right)
Coronal T2WI FSE MR in the
same patient shows the large
T2 hyperintense mass ,
with regions of liquefaction
corresponding to necrosis .

MR in the same patient
shows the large mass to
be heterogeneous with an
enhancing solid component
with regions of necrosis
. Surgical pathology proved
to be an endometrial stromal
sarcoma (Right) Axial CECT
in a patient with endometrial
stromal sarcoma shows a large
heterogeneous soft tissue mass
with foci of necrosis in
the uterus.
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ENDOMETRIAL STROMAL SARCOMA
Uterus
o Restricts diffusion
TERMINOLOGY
• T1WI C+
Synonyms o Heterogeneous enhancement less avid than
• Uterine sarcoma myometrium
▪ Portions of tumor may demonstrate marked
Definitions enhancement (greater than myometrium)
• Malignant mesenchymal tumor of endometrium
IMAGING
o Transvaginal ultrasound (TVUS) nonspecific
General Features ▪ Heterogeneous, mixed echogenicity endometrial-
• Best diagnostic clue based mass, endo- and myometrial thickening, and
adnexal masses
o Large, heterogeneous, endometrial-based mass with a
predominant myometrial component • Pulsed Doppler
o Spread along fallopian tubes, uterine ligaments, and o Low-impedance flow
adjacent pelvic veins • Color Doppler
o Low-grade stromal sarcoma (LGSS): Bands of o Increased vascularity
low signal intensity (SI) on T2WI within area of Imaging Recommendations
myometrial invasion
o High-grade (HGSS): Infiltrative borders with nodular • Best imaging tool
o Role of imaging is to suggest diagnosis and define
lesions at tumor margin, intramyometrial nodular
disease extent for treatment planning
masses, areas of hemorrhage and necrosis o High-resolution pelvic MR is modality of choice for
• Location
diagnosis and local staging
o Arise from endometrium o CT can be used in advanced disease with distant
o May be entirely myometrial
spread
o Rarely originate from foci of adenomyosis or
endometriosis
• Protocol advice
o Pelvic MR with phased-array coil, 4-5 mm slice
• Size
thickness
o Large; mean: 9 cm
▪ Axial T1WI with larger field of view (FOV) from
• Morphology pelvis to kidneys for lymph nodes
o Endometrial thickening/polypoid intrauterine mass ▪ Axial, sagittal, and coronal (short-axis) T2WI with
o Overlap between imaging findings of low- and high-
small FOV
grade tumors ▪ Sagittal and coronal (short-axis) dynamic T1WI C+
▪ HGSS: Infiltrative lesions with necrosis FS with small FOV
and hemorrhage, marginal nodularity and
intramyometrial nodules representing
intravascular/lymphatic tumor spread DIFFERENTIAL DIAGNOSIS
CT Findings Endometrial Carcinoma
• NECT • Typically smaller than endometrial stromal sarcomas
o Uterine enlargement, high attenuation in • More homogeneous with absence of necrosis
hemorrhagic areas
• CECT
Other Uterine Sarcomas
• Difficult to differentiate from endometrial stromal
o Heterogeneously enhancing mass resulting in uterine
sarcoma
enlargement
o Loss of pelvic fat planes with extrauterine extension Degenerated Leiomyoma
o Useful for detection of lymphadenopathy and distant • Persistent areas of low SI intensity on T2WI
metastases • Well-defined borders, absence of invasion
MR Findings Adenomyosis
• T1WI • Diffuse or focal thickening of junctional zone
o Homogeneous, low- to intermediate-SI mass
▪ High SI in hemorrhagic areas
• Bulk of lesion is of low SI on T2WI
o Small foci of high SI on T2WI are common,
• T2WI
myometrial cysts
o Heterogeneous mass, iso- or slightly hypointense
relative to normal endometrium Benign Endometrial Stromal Nodule
o LGSS: Low SI bands reflecting preserved bundles of • Well-circumscribed, expansile neoplasm
myometrium between worm-like tumor plugs
o HGSS: May present as high-SI nodular lesions at
• No invasive features
tumor margin and myometrial nodules Intravenous Leiomyomatosis
• STIR • Low SI uterine mass involving myometrium and
o Hyperintense tumor; hemorrhagic components can extending beyond uterus
be low SI • Tumor may extend into inferior vena cava (IVC) and
• DWI heart
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Uterus ENDOMETRIAL STROMAL SARCOMA
PATHOLOGY Natural History & Prognosis

General Features
o Histologic grade of tumor (DNA index)
• Etiology o Stage of disease
o No association with unopposed estrogen or prior
• Lung and liver most common sites of distant metastases
pelvic radiation
o Originates from endometrial tissue, rarely from
• 5-year survival rates
o LGSS: Stage I > 80%
adenomyosis or endometriosis o HGSS: Stage I 50%
Staging, Grading, & Classification o All tumor grades: Stage II 30%, stage III-IV 10%
• Classified as low- and high-grade tumors Treatment
• New FIGO stage for endometrial sarcoma • Total abdominal hysterectomy, bilateral salpingo-
o Stage IA : Tumor limited to uterus < 5 cm oophorectomy, and lymph node sampling
▪ Stage IB: Tumor limited to uterus > 5 cm
o Stage IIA: Tumor extends to pelvis, adnexal
• Radiation therapy for local control in setting of poor
prognostic markers
involvement
▪ Stage IIB: Tumor extends to extrauterine pelvic
tissue DIAGNOSTIC CHECKLIST
o Stage IIIA: Tumor invades abdominal tissues, 1 site
Consider
▪ Stage IIIB: > 1 site
– Stage IIIC: Metastasis to pelvic &/or paraaortic
• Consider endometrial stromal sarcoma in differential
diagnosis of heterogeneous, endometrial-based mass
lymph nodes with significant myometrial component
o Stage IVA: Tumor invades bladder &/or rectum
▪ Stage IVB: Distant metastases Image Interpretation Pearls
Gross Pathologic & Surgical Features • Bands of low SI on T2WI within myometrium
• Fungating/papillary mass filling endometrial cavity or • Spread along fallopian tubes, uterine ligaments and
gross intravascular tumor extension
infiltrating myometrium and adjacent structures
• Hemorrhage and necrosis are frequently present,
particularly in HGSS SELECTED REFERENCES
Microscopic Features 1. Yoon A et al: Prognostic factors and outcomes in
• LGSS: Uniform cells nearly identical to proliferative endometrial stromal sarcoma with the 2009 FIGO staging
system: a multicenter review of 114 cases. Gynecol Oncol.
phase endometrial stromal cells
132(1):70-5, 2014
o Little pleomorphism, low mitotic rates
2. Tirumani SH et al: Current concepts in the imaging of
o Lymphatic and vascular space invasion uterine sarcoma. Abdom Imaging. 38(2):397-411, 2013
• HGSS: Nuclear pleomorphism and high mitotic rates 3. Seddon BM et al: Uterine sarcomas--recent progress and
o Destructive myometrial invasion, in contrast to future challenges. Eur J Radiol. 78(1):30-40, 2011
permeative invasion of LGSS 4. Tse KY et al: Staging of uterine sarcomas. Best Pract Res Clin
Obstet Gynaecol. 25(6):733-49, 2011
5. Wu TI et al: Clinical presentation and diagnosis of uterine
CLINICAL ISSUES sarcoma, including imaging. Best Pract Res Clin Obstet
Gynaecol. 25(6):681-9, 2011
Presentation 6. Chew I et al: Endometrial stromal sarcomas: a review of
• Most common signs/symptoms potential prognostic factors. Adv Anat Pathol. 17(2):113-21,
o Abnormal vaginal bleeding 2010
• Other signs/symptoms 7. Fujii S et al: Diffusion-weighted imaging of uterine

endometrial stromal sarcoma: a report of 2 cases. J Comput
o Abdominal pain or mass Assist Tomogr. 34(3):377-9, 2010
• Clinical profile 8. Furukawa R et al: Endometrial stromal sarcoma located in
o LGSS: Due to young age at presentation, clinical the myometrium with a low-intensity rim on T2-weighted
diagnosis is typically leiomyoma or adenomyosis images: report of three cases and literature review. J Magn
Reson Imaging. 31(4):975-9, 2010
with an unusual degree of bleeding
o Diagnosis of HGSS is readily made at dilatation and 9. Sohaib SA et al: Imaging of uterine malignancies. Semin
Ultrasound CT MR. 31(5):377-87, 2010
curettage (D&C ) 10. Nugent EK et al: The value of perioperative imaging
Demographics in patients with uterine sarcomas. Gynecol Oncol.
• Age 115(1):37-40, 2009

11. Moinfar F et al: Uterine sarcomas. Pathology. 39(1):55-71,
o Most common between 35-55 years 2007
▪ LGSS: Young premenopausal women (mean: 40 12. Kusaka M et al: A case of high-grade endometrial stromal
years) sarcoma arising from endometriosis in the cul-de-sac. Int J
▪ HGSS: Postmenopausal women (mean: 60 years) Gynecol Cancer. 16(2):895-9, 2006
• Epidemiology
o 1% of uterine malignancies, 10-25% of primary
uterine sarcomas
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Uterus
(Left) Sagittal T1WI C+ FS MR
through the pelvis shows a large
necrotic tumor replacing the
endometrial cavity and anterior
myometrium. Surgical resection
proved this to be endometrial
stromal sarcoma. (Right) Coronal
T1WI C+ FS MR in same patient
shows the large necrotic uterine
tumor , surgically confirmed
to be endometrial stromal cell
sarcoma.
(Left) Axial CECT through

the pelvis shows a large soft
tissue mass replacing the
endometrium and myometrium.
Note the calcified fibroid
engulfed by the sarcoma. (Right)
shows the polypoid nature of
the soft tissue mass replacing
the uterus in this patient with
endometrial sarcoma.

in a patient with pelvic mass
shows heterogeneous polypoid
soft tissue mass within the
uterus, extending to the posterior
pelvic side wall . Biopsy
confirmed endometrial stromal
cell sarcoma. (Right) Sagittal
T2WI FSE MR in the same patient
shows the necrotic polypoid
mass emanating from uterine
endometrium and invading
the myometrium. Note the
bulk of the tumor is seen in the
myometrium.
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Uterus GESTATIONAL TROPHOBLASTIC DISEASE

(T) Primary Tumor
T1 I Tumor confined to uterus
T2 II Tumor extends to other genital structures (ovary, tube, vagina, broad ligaments) by
metastasis or direct extension
(M) Distant Metastasis

M0 No clinical metastasis
M1 Distant metastases
M1a III Lung metastasis
M1b IV All other distant metastasis
Prognostic Scoring Index for

Gestational Trophoblastic Tumors
Risk Factors 0 1 2 4
Age < 40 years ≥ 40 years
Antecedent pregnancy Mole Abortion Term pregnancy
Interval months from index pregnancy <4 4-6 7-12 > 12
Pretreatment serum hCG (IU/L) < 10³ 10³ to < 10⁴ 10⁴ to < 10⁵ ≥ 10⁵
Largest tumor size in cm <3 3-5 >5
Site of metastases Lung Spleen, kidney GI tract Brain, liver
Number of metastases 1-4 5-8 >8
Previous failed chemotherapy Single drug ≥ 2 drugs

AJCC Stages/Prognostic Groups
Stage T M Risk Factors
I T1 M0 Unknown
IA T1 M0 Low risk
IB T1 M0 High risk
II T2 M0 Unknown
IIA T2 M0 Low risk
IIB T2 M0 High risk
III Any T M1a Unknown
IIIA Any T M1a Low risk
IIIB Any T M1a High risk
IV Any T M1b Unknown
IVA Any T M1b Low risk
IVB Any T M1b High risk
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GESTATIONAL TROPHOBLASTIC DISEASE
Uterus
Complete Hydatidiform Mole Partial Hydatidiform Mole
H&E stain shows 2 key features of a complete hydatidiform mole: H&E stain shows a mixture of enlarged, edematous villi with cisterns
Trophoblastic proliferation and villous edema. Note the enlarged and small, normal-sized villi with fibrotic stroma . The large
villus that has central cistern (entirely acellular space), stromal villi have scalloped surfaces with trophoblast infolding, forming
edema, and a circumferential proliferation of trophoblasts around inclusions. The trophoblastic proliferation is focal and composed of
the surface. haphazard tufts of trophoblasts.
Choriocarcinoma Placental-Site Trophoblastic Tumor
High magnification of an H&E-stained section shows highly atypical H&E stain shows sheets of intermediate trophoblasts, characterized
cytotrophoblast cells with irregular hyperchromatic nuclei mixed by large polygonal cells with irregular nuclei and dense eosinophilic
with syncytiotrophoblasts. cytoplasm. In contrast, choriocarcinoma is composed of a mixture
of cytotrophoblasts, syncytiotrophoblasts, and intermediate
trophoblasts.
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T1: Gestational Trophoblastic Disease T1: Gestational Trophoblastic Disease
This graphic demonstrates the uterus in the coronal plane and A cut section of the uterus as viewed from above demonstrates
shows gestational trophoblastic disease that is either limited to the gestational trophoblastic disease that is either limited to the
endometrium or invades into the myometrium . In T1 disease, endometrium or invades into the myometrium . In T1 disease,
the tumor is confined to the uterus. the tumor is confined to the uterus.
Coronal graphic illustrates gestational trophoblastic disease Graphic demonstrates a cut section of the uterus as viewed from
extending to the broad ligament and involving the vagina . above and shows the tumor extending to the broad ligament
Either circumstance would constitute T2 disease, in which the and involving the vagina . In T2 disease, the tumor extends
tumor extends outside the uterus but is limited to the genital tract. outside the uterus but is limited to the genital tract.
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Uterus
This coronal graphic shows gestational trophoblastic disease Graphic demonstrates a cut section of the uterus as viewed from
extending to the fallopian tube and involving the ovary . In above and shows gestational trophoblastic disease extending to the
T2 disease, the tumor extends outside the uterus but is limited to fallopian tube and broad ligament . In T2 disease the tumor
the genital tract. extends outside the uterus but is limited to the genital tract.

Lung 80%
Vagina 30%
Brain 10%
Liver 10%
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▪ Risk increases 10x in patients with previous molar

OVERVIEW pregnancy
o Choriocarcinoma may develop after any type of
General Comments
pregnancy
• Broad spectrum of conditions characterized by ▪ 70% develop after complete mole
abnormal proliferation of trophoblastic tissue
▪ 20% after abortion or tubal pregnancy
Classification ▪ 10% after term pregnancy
• Gestational trophoblastic disease (GTD) includes • Epidemiology & cancer incidence
o Hydatidiform mole o GTD is uncommon (overall 1 in 1,000 pregnancies)
▪ Complete hydatidiform mole (CHM) ▪ Incidence varies by geographical location
▪ Partial hydatidiform mole (PHM) – ~ 1 in 2,000 pregnancies in Europe and USA
o Invasive hydatidiform mole (chorioadenoma – ~ 1 in 500 pregnancies in Japan, Singapore, and
destruens) (IHM) Malaysia
o Choriocarcinoma ▪ Incidence varies by age
o Placental site trophoblastic tumor (PSTT) – 2 peaks of occurrence in women (< 20 or > 40
o Epithelioid trophoblastic tumor years of age)
• Gestational trophoblastic neoplasia (GTN) includes – > 5x increased risk in women > 40 years
o Persistent hydatidiform mole o Choriocarcinoma is rare (1 in 20,000 pregnancies)
o IHM • Associated diseases, abnormalities
o Choriocarcinoma o Theca lutein cysts
o PSTT ▪ Result from ovarian hyperstimulation due to high
circulating levels of β-hCG
▪ Often resolve 2-4 months following molar
PATHOLOGY evacuation, though regression process generally
takes longer than decline in β-hCG levels
Routes of Spread ▪ Occur more frequently with invasive moles and
• CHM and PHM choriocarcinoma than in complete moles
o By definition, benign localized tumors with – 13.8% of complete moles
malignant potential – 57.9% of invasive moles
o Confined to uterus without myometrial invasion – 33.3% of choriocarcinoma
• IHM o Uterine vascular malformations
o CHM or PHM that invades myometrium ▪ GTD is highly vascular and associated with uterine
o Hematogenous metastases can occur to lungs and vascular malformations
brain ▪ Vascular malformations persist in 10–15% of
o Vaginal metastases can occur via retrograde spread patients, even after complete tumor resolution
through parauterine veins following chemotherapy
• Choriocarcinoma ▪ Majority are supplied predominantly by uterine
o Highly vascular with possible hematogenous spread arteries
to lungs, brain, and liver ▪ 1-2% of uterine vascular malformations cause
o Vaginal metastases are more common than in IHM vaginal or intraperitoneal hemorrhage
• PSTT Gross Pathology & Surgical Features
o Tends to spread locally to uterus
o Can involve lymph nodes, which is uncommon with • CHM
o Large-for-dates uterus
other GTN
o Bulky mass, sometimes consisting of > 500 cc of
General Features bloody tissue
• Comments o Classic "bunch of grapes" appearance
o GTD encompasses heterogeneous family of lesions ▪ Large villi forming transparent vesicles of variable
▪ Arise from various trophoblast subpopulations size (1-30 mm)
▪ Different malignant potential o No normal placental tissue is apparent
• Genetics o Absent embryo or fetus
o CHM and IHM show diploid karyotype; completely • Partial hydatidiform mole
of paternal origin in majority of patients (46,XX) o Volume of tissue is often < 300 cc
▪ Single haploid sperm fertilizing ovum lacking o Only proportion of villi are vesicular
maternal genes → duplication o Presence of embryonic or fetal tissues
▪ 2 sperm fertilizing ovum lacking maternal genes ▪ Most spontaneously abort by 20 weeks
o PHM shows triploid karyotype • IHM
▪ 2 sperm fertilizing normal ovum o Pathologic diagnosis of invasive mole is rarely made
o Choriocarcinoma shows many abnormal karyotypes because most cases are treated medically, without
and can follow normal pregnancy hysterectomy
• Etiology o All cases of invasive mole are sequelae of
o Most important risk factor in development of GTD is hydatidiform moles
previous molar pregnancy o Molar villi grow into myometrium or its blood vessels
2
o May extend into broad ligament and other pelvic
organs
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o Rarely metastatic
▪ Metastasizes to lungs and brain IMAGING FINDINGS
• Choriocarcinoma Detection
o May arise after normal (1 in 25,000) or abnormal
pregnancy
• Ultrasound
o CHM
o Dark red hemorrhagic mass with shaggy irregular
▪ Early in pregnancy
surface
o Usually myometrial in location but can invade into – Enlarged uterus filled with solid hyperechoic
tissue
surrounding structures
– Only 56% of CHM shows cysts in 1st trimester
• PSTT – GS surrounding echogenic mass may be seen
o Rare tumor arising from placental implantation site
o Can develop from normal pregnancy, abortion, – Can be difficult to differentiate early CHM
from retained products of conception following
CHM, or PHM
o Slow growing miscarriage
o Variable in size but may present with diffuse nodular ▪ Late in pregnancy
– Hydropic villi appear as multiple anechoic spaces
thickening of myometrium
o Occasionally polypoid mass projecting into uterine 1-30 mm in diameter
– Cysts become more numerous and visible in 2nd
cavity
trimester
Microscopic Pathology ▪ Low-resistance arterial flow on Doppler
• H&E interrogation (resistive index [RI] ~ 0.55)
o CHM ▪ 5 sonographic features are more often seen with
▪ Lack of embryonic or fetal tissues GTD compared to retained products of conception
▪ Cyst-like hydropic swelling of chorionic villi – Myometrial epicenter
▪ Diffuse trophoblastic hyperplasia – Depth of myometrial invasion > 1/3
▪ Disintegration and loss of blood vessels in villous – Placental venous lakes
core – Maximum mass dimension > 3.45 cm
▪ Diffuse and marked trophoblastic atypia at – Maximum endometrial thickness < 12 mm
implantation site ▪ Theca lutein cysts: Large ovaries with multiple
▪ Premalignant disease anechoic cysts
– 16% of complete moles transform into o PHM
malignant GTD ▪ Size of placenta depends on genetic profile
o PHM – Large placenta with focal numerous cysts if extra
▪ Presence of embryonic or fetal tissues paternal chromosome (69,XXY)
▪ Focal trophoblastic hyperplasia – Small placenta if extra maternal chromosome
▪ Variable, usually less intense, hydropic swelling of (69,XXX)
chorionic villi ▪ Maintained overall shape of placenta
▪ Focal and mild trophoblastic atypia at ▪ GS is present
implantation site ▪ Ratio of transverse to anteroposterior diameter of
▪ Premalignant disease GS > 1.5
– 0.5% of partial moles can transform into ▪ Abnormal fetus with multiple anomalies and
malignant GTD growth restriction
o IHM o IHM
▪ Molar pregnancy in which molar villi grow into ▪ CHM with myometrial invasion
myometrium or its blood vessels o Choriocarcinoma
▪ Molar villi with trophoblasts within myometrium ▪ Uterine disease may be absent in patients with
or at extrauterine site metastatic disease
o Choriocarcinoma ▪ Focally irregular, echogenic, heterogeneous regions
▪ Malignant neoplasm of trophoblastic epithelium within myometrium
▪ Masses and sheets of trophoblastic cells without ▪ Sonolucent areas surrounding echogenic foci
villi invading surrounding tissue and permeating correspond to myometrial hemorrhage
vascular spaces ▪ Highly vascular on Doppler US
▪ Spread to distant sites o PSTT
▪ Most cases present within year of antecedent ▪ Heterogeneous hyperechoic mass with cystic
pregnancy changes within myometrium
– However, cases described after latent periods of ▪ Doppler US: Both hypervascular and hypovascular
up to 25 years forms have been described
o PSTT • CT
▪ Neoplastic proliferation of intermediate o Limited role in detection of GTD
trophoblasts that invade myometrium at placental o Complete and partial hydatidiform mole
site ▪ Heterogeneously enhancing endometrial mass
▪ Relatively poorly vascularized ▪ Reticular pattern of enhancement between low-
▪ Serum hCG only modestly elevated due to lack of signal vesicles
o IHM
syncytiotrophoblastic tissue
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▪ Similar to hydatidiform mole with myometrial ▪ Patterns of lung involvement

invasion – Discrete rounded densities
o Choriocarcinoma and PSTT – Alveolar or "snowstorm" pattern
▪ Myometrial mass ± endometrial component – Pleural effusion
▪ Heterogeneous enhancement with prominent – Embolic pattern caused by pulmonary arterial
enhancing vessels occlusion
• MR – Arteriovenous fistulae can occur
o CHM o Liver metastases may be diagnosed by CT or
▪ T1WI: Isointense to myometrium (areas of ultrasound imaging
hemorrhage are hyperintense) ▪ Occur late
▪ T2WI: Markedly hyperintense mass distends ▪ Poor prognosis
endometrial cavity ▪ Can be hemorrhagic and enhance avidly after
▪ Gadolinium-enhanced T1WI: Numerous cystic contrast administration
areas may be seen in mass ▪ Hypervascular mass with aneurysmal dilatation of
▪ Normal myometrium surrounds mass intraparenchymal hepatic artery on arterial phase
o PHM and vascular lakes on venous phase is characteristic
▪ Appears as CHM appearance
▪ Abnormal fetus may be identified o Brain metastases
o IHM ▪ MR is preferred for staging of brain metastases
▪ Endometrial mass with irregular interface between – CT can be used as alternative
mass and myometrium ▪ Imaging features
▪ Disruption of junctional zone may be seen – Usually multiple
▪ T1WI: Isointense to myometrium with scattered – Occur at gray–white matter junction
foci of high signal intensity because of hemorrhage – Most commonly in parietal lobe
▪ T2WI: Heterogeneous mixed signal intensity with – Surrounding edema and secondary hemorrhage
myometrial invasion – Cerebral metastases enhance avidly
▪ Gadolinium-enhanced T1WI: Vesicular structures – Many lesions show high attenuation on
appear as tiny low-signal structures within unenhanced CT
enhanced zone of trophoblastic proliferation – On MR signal characteristics are variable
o Choriocarcinoma and PSTT depending on age of associated hemorrhage
▪ MR findings are not specific ▪ CTA, MRA, and cerebral angiography can show
▪ Numerous signal voids on all sequences arteriovenous fistulae
▪ Myometrial mass ± endometrial component ▪ β-hCG level should be used to screen for GTN
▪ T1WI: Iso- or hyperintense to myometrium in any woman of reproductive age with brain
▪ T2WI: Slightly to markedly hyperintense to metastasis or cerebral hemorrhage of unexplained
myometrium etiology
▪ Prominent blood vessels are seen in most cases o Intraabdominal metastases
▪ Arterial phase dynamic gadolinium-enhanced ▪ Abdominal CT scanning is preferred
images: Prominent enhancing vessels o Vaginal metastases
▪ 30% of patients with metastatic GTN
Staging ▪ Most commonly located suburethrally or in
• Local staging fornices
o Imaging is indicated in patients with persistent ▪ Highly vascular and may bleed vigorously if
trophoblastic disease biopsied
▪ MR is superior to CT and US in establishing • PET/CT
myometrial invasion in GTN o May identify occult disease not seen with other
▪ MR and CT can be used to evaluate for extrauterine imaging modalities
genital involvement
– Manifests as enhancing parametrial soft tissue
mass CLINICAL ISSUES
• Nodal staging
o Nodal involvement is rare in GTN Presentation
▪ More common with PSTT • Hydatidiform mole
o Both CT and MR can be used to evaluate for regional o 1st or 2nd trimester presentation
adenopathy ▪ Vaginal bleeding
o No regional nodal designation in staging of GTN ▪ Rapid uterine enlargement
▪ Classified as metastatic M1 disease ▪ Large uterine size for dates (> 4 weeks larger than
• Metastatic disease gestational age)
o Lung involvement ▪ Hyperemesis gravidarum
▪ Chest x-ray is adequate to diagnose lung metastasis ▪ Preeclampsia before 24 weeks
and is used for counting number of lung metastases ▪ Absence of fetal heart tones
to determine risk factor score ▪ β-hCG is greater than expected for gestational age
– Chest CT may be used as alternate ▪ Expulsion of vesicles (80%)
2 – Use of chest CT instead of chest x-ray in staging

of GTN does not alter outcome
• GTN
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o Should be considered in cases of persistent abnormal o Stage IV
bleeding following normal pregnancy, abortion, or ▪ Combination chemotherapy
ectopic pregnancy ▪ Whole-brain irradiation for cranial metastases
o Persistently rising or plateauing β-hCG levels after ▪ Hysterectomy to control bleeding or sepsis
evacuation of molar pregnancy ▪ Surgical resection of resistant metastatic lesions
o FIGO Council 2000 criteria for diagnosis of post
hydatidiform mole GTN
▪ Rise in β-hCG level of ≥ 10% of 3 values recorded REPORTING CHECKLIST
over 2 weeks (days 1, 7, and 14)
▪ Plateau in β-hCG level (± 10%) of 4 values T Staging
recorded over 3 weeks (days 1, 7, 14, and 21) • Evaluate for myometrial and extrauterine involvement
▪ Persistence of detectable β-hCG level at 6 months o MR is superior to CT and US
or more after evacuation of mole
▪ Histologic diagnosis of choriocarcinoma
N Staging
• No regional nodal designation in staging of GTN
Cancer Natural History & Prognosis • Nodal metastases are rare except with PSTT
• CHM and PHM require only uterine evacuation for • Can affect pelvic and inguinal lymph nodes
complete cure • Nodal metastases are classified as metastatic M1 disease
• Cure rate approaches 100% for other invasive tumors M Staging
with appropriate chemotherapy
• Lung metastases are most common
Treatment Options o Chest x-ray is adequate for staging
• Major treatment alternatives • Abdominal metastases
o CHM and PHM o Appear as enhancing masses, usually in liver or
▪ Evacuation with suction curettage spleen
▪ Hysterectomy in patients who do not want to o CT is modality of choice
preserve fertility • Brain metastases
▪ Serial hCG measurement weekly until undetectable o Heterogeneous lesions with avid enhancement
for 3 weeks and then monthly for 6 months o MR is modality of choice
o PSTT
▪ Hysterectomy (relatively chemoresistant)
o GTN SELECTED REFERENCES
▪ Single or combination chemotherapy depending 1. American Joint Committee on Cancer: AJCC Cancer Staging
on stage and risk factors Manual. 7th ed. New York: Springer. 437-44, 2010
▪ Hysterectomy 2. Berkowitz RS et al: Current management of gestational
o Uterine vascular malformations trophoblastic diseases. Gynecol Oncol. 112(3):654-62, 2009
▪ Treated either by uterine artery embolization or by 3. Darby S et al: Does chest CT matter in the staging of GTN?
hysterectomy Gynecol Oncol. 112(1):155-60, 2009
• Treatment options by stage 4. Allen SD et al: Radiology of gestational trophoblastic
o GTD is effectively treated with chemotherapy, even neoplasia. Clin Radiol. 61(4):301-13, 2006
5. Betel C et al: Sonographic diagnosis of gestational
when widely metastatic trophoblastic disease and comparison with retained
o Traditional staging based on anatomical tumor products of conception. J Ultrasound Med. 25(8):985-93,
location is not adequate to fully categorize patients 2006
for treatment and prognosis 6. Brandt KR et al: MR appearance of placental site
o Other prognostic factors have been added to guide trophoblastic tumor: a report of three cases. AJR Am J
therapy Roentgenol. 170(2):485-7, 1998
▪ Cumulative score ≤ 6 is considered low-risk disease 7. Green CL et al: Gestational trophoblastic disease: a spectrum
of radiologic diagnosis. Radiographics. 16(6):1371-84, 1996
treatable by single-agent chemotherapy 8. Wagner BJ et al: From the archives of the AFIP. Gestational
▪ Cumulative score ≥ 7 is high-risk disease that trophoblastic disease: radiologic-pathologic correlation.
requires combination chemotherapy Radiographics. 16(1):131-48, 1996
o Stage I (low-risk GTN)
▪ Single-agent chemotherapy with either
methotrexate (MTX) or actinomycin D (ACTD)
▪ Single-agent chemotherapy with sequential MTX/
ACTD
▪ Hysterectomy + single-agent chemotherapy if
patient does not desire to retain fertility
▪ Combination chemotherapy in patients who
develop resistance to single-agent chemotherapy
▪ Hysterectomy in patients who develop resistance to
combination chemotherapy
o Stage I (high-risk GTN), II, and III
▪ Combination chemotherapy with etoposide,
2
MTX, ACTD, cyclophosphamide, and vincristine
(Oncovin) (EMACO)
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Complete Hydatidiform Mole (Early) Complete Hydatidiform Mole (Early)

in a patient presenting
in the 1st trimester with
hyperemesis shows an
echogenic endometrial mass
distending the uterine
cavity. Note the lack of cystic
changes, which is typical for
a hydatidiform mole in the 1st
trimester. (Right) Longitudinal
duplex Doppler ultrasound in
the same patient shows that
the mass is highly vascular
with low-resistance arterial
flow.
Complete Hydatidiform Mole (Late) Complete Hydatidiform Mole (Late)

shows a uterine mass in
a pregnant woman with
marked elevation of β-hCG in
the 2nd trimester. The mass
is echogenic and contains
multiple small cysts. The
increased echogenicity of the
mass is due to the presence
of innumerable small
cysts below the resolution
of ultrasound. (Right)
Longitudinal ultrasound
the uterine mass with
multiple, small, cystic areas
representing the hydropic
villi. No fetal parts are seen.
Complete Hydatidiform Mole Complete Hydatidiform Mole

a patient with rising β-hCG
3 weeks after an abortion
shows a fundal high-intensity
mass without invasion
into the myometrium.
Although the appearance
is nonspecific and can be
seen with retained products
of conception, pathology
after suction and curettage
confirmed the diagnosis.
same patient shows the mass
with small signal void
structures representing
prominent vessels.
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(Left) In the same patient,
sagittal T1WI C+ FS MR also
shows an enhancing fundal
mass without evidence
of myometrial invasion.
(Right) Axial T1WI C+ FS
demonstrates the enhancing
fundal mass . The degree
of enhancement correlates
with the amount of active
trophoblastic tissue and
the level of β-hCG. Note
the increased parametrial
vascularity .

(Left) Axial CECT at the
level of the uterus shows
a distended uterine cavity
with mixed density soft
tissue representing a
molar pregnancy. There is
no evidence of extrauterine
involvement. (Right) Axial
shows distended uterus with
areas of increased vascularity
at the periphery of the uterine
mass . Both ovaries are
enlarged and contain
multiple large cysts, which
represent theca lutein cysts.

marked enlargement of the
uterus . The uterus is filled
with predominantly low-
density material representing
abnormal hydropic villi
with enhancing septa
giving the uterine contents a
reticular appearance. (Right)
Sagittal CECT MIP image
marked uterine enlargement
with the fundus above
the umbilicus . The molar
pregnancy distends the cervix
and fills the vagina .
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Partial Hydatidiform Mole (Early) Partial Hydatidiform Mole (Late)

ultrasound in an early
pregnancy shows a
yolk sac adjacent to
echogenic trophoblastic
tissue . (Right) Transverse
shows a large placenta with
focal cystic changes .
Other parts of the placenta
appear normal. Fetal
parts are seen. The fetus
showed growth restriction
and multiple anomalies.
Cystic placental changes are
seen in triploidy if the extra
set of chromosomes is of
paternal origin.
Invasive Mole Invasive Mole

high signal intensity mass ,
which fills the uterine cavity
and appears to be limited
to the endometrium. (Right)
patient shows a retroverted
uterus containing an
abnormal high T2 signal mass
that fills the uterus. Note the
sharp interface between the
mass and the myometrium
of the posterior uterine wall
, as well as the loss of
endometrial-myometrial
interface of the anterior wall
due to tumor invasion .
Invasive Mole Invasive Mole

an endometrial mass that
is isointense to the normal
myometrium. High signal
intensity intraluminal blood
is also seen . (Right)
enhancing circumferential
endometrial mass with
focal extension into the
myometrium along the
anterior wall. Compare this to
the well-defined endometrial-
myometrial interface along
the posterior wall.
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Choriocarcinoma Choriocarcinoma
old woman who presented
with vaginal bleeding 3
months after full-term
delivery shows an enhancing,
predominantly endometrial
mass distending the
uterine cavity with ill-
defined interface with the
myometrium . Note the
increased vascularity within
the underlying myometrium
. (Right) Coronal CECT
the enhancing mass
invading into the myometrium
without extrauterine
extension.
predominantly myometrial
mass of high signal
intensity in the region of the
fundus. (Right) Axial T2WI
the hyperintense myometrial
fundal mass indenting
the endometrium . Note
also the prominent vessels
appearing as round and
tubular signal voids within
the myometrium.
in the same patient shows an
enhancing fundal mass .
The mass shows more intense
enhancement compared to
the adjacent myometrium,
indicating its high vascularity.
intense enhancement of the
mass .
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a patient with elevated β-
hCG 3 months after the
conclusion of a normal
pregnancy shows a large
high signal intensity mass
that appears to distend
the uterine cavity with poor
interface. (Right) Axial T2WI
a heterogeneous high signal
intensity mass filling the
uterine cavity. Myometrial
invasion is not clear on these
images. Note the low signal
intensity septa within the
mass .
enhancing fundal mass
that invades the myometrium
and extends to the serosal
surface of the uterus .
This shows that the mass
is actually myometrial in
location with displacement of
the enhancing endometrium
. (Right) Axial T1WI C+ FS
the enhancing, predominantly
myometrial mass that
displaces the enhancing
endometrium .
year-old woman, presenting
with persistent elevation
of β-hCG 3 months after
spontaneous abortion, shows
a fundal mass that is
predominantly of high T2
signal intensity with a central
area of low signal intensity
, likely due to intralesional
bleeding. (Right) Axial
T1WI C+ FS MR shows a
peripherally enhancing fundal
mass that reaches to the
serosal surface without
extrauterine extension.
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T1: Placental-Site Trophoblastic Tumor T1: Placental-Site Trophoblastic Tumor
shows a fundal mass of
low signal intensity relative
to the myometrium with
small intralesional foci of
high T2 signal intensity in
had an abortion at 7 weeks
gestational age and continued
to have elevated β-hCG. The
mass extends to the serosal
surface without penetrating
the serosa. (Right) Axial T1WI
that the uterine mass is
isointense to the myometrium
on T1W images.

the same patient shows an
endometrial mass of low
signal intensity relative to
the myometrium. (Right)
patient at a higher level
shows the low T2 signal
mass extending into
the myometrium to the
serosal surface without
actual serosal penetration.
At hysterectomy, the mass
was confined to the uterus
without extension to other
pelvic organs, consistent with
T1 disease.

(Left) Axial T1WI C+ FS MR in
the same patient shows that
the endometrial/myometrial
mass is poorly enhancing
relative to the normally
enhancing myometrium.
(Right) Coronal T1WI C+
shows the hypovascular mass
within the myometrium.
Both enhancing and
poorly enhancing patterns
may be seen on imaging,
which correspond to
the hypervascular and
hypovascular patterns seen
on pathologic evaluation,
respectively.
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who presented with modest
elevation of β-hCG following
a normal pregnancy shows
a highly vascular mass
that invades the myometrium.
The uterus is filled with high-
density material due to
an intraluminal hemorrhage.
same patient shows a highly
vascular myometrial mass
with tumor extending
into the left parametrium .
Extrauterine tumor extension
constitutes T2 disease.

anterior wall myometrial mass
of high signal intensity in
a retroverted uterus. Note the
multiple signal void structures
within the mass due
to a rich vascular supply.
mass of high signal intensity
containing multiple
signal void-like rounded and
tubular structures due to
increased vascularity.

demonstrates the enhancing,
highly vascular myometrial
mass , and blood filling
the uterine cavity. This case
represents the highly vascular
pattern of PSTT. (Right)
Axial T1WI C+ FS MR in
highly vascular mass with
The uterine cavity is filled
with high T1 signal intensity
blood products . Left
parametrial tumor extension
is seen.
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Post-Treatment Arteriovenous Fistula Post-Treatment Arteriovenous Fistula
(Left) This patient received
single-agent chemotherapy
for treatment of an invasive
mole and presented with
vaginal bleeding. This axial
T1WI C+ FS MR shows a
fluid-filled cavity at the
site of the treated mass that
contains multiple large blood
vessels at its periphery .
the retroverted uterus and
a large cavity with large
serpiginous vessels at the
periphery of the cavity.
Metastatic Choriocarcinoma Metastatic Choriocarcinoma

(Left) Axial CECT in lung
window shows a round,
soft tissue-density nodule in
the left upper lobe in a
patient with an invasive mole
diagnosed after CHM. (Right)
Axial CECT in lung widow in
the same patient obtained 3
months later, after the patient
received methotrexate, shows
almost complete resolution
of the nodule . Two other
smaller nodules completely
resolved with treatment.
Metastatic Choriocarcinoma Metastatic Choriocarcinoma

with persistent elevation of
β-hCG shows an intensely
enhancing splenic mass .
The patient also had lung
metastases. It is uncommon
for patients with gestational
trophoblastic neoplasia to
present with abdominal
metastases in the absence
of lung metastases. (Right)
Coronal T1WI C+ MR shows
an enhancing lesion in the
left parietal region with
surrounding edema .
2
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Uterus UTERINE ARTERIOVENOUS MALFORMATION
Key Facts
Imaging • Angiographic findings
• US o Complex tangle of vessels
o Hypertrophied feeding uterine arteries (single or
o Small anechoic spaces distributed uniformly
producing "spongy" myometrial echotexture bilateral)
o No associated mass effect o Early venous drainage in arterial phase of contrast
o Stasis of contrast within abnormal vessels in later
• Doppler US
phases of contrast
o 2 mosaic patterns of color: Apparent flow reversal
and color aliasing Top Differential Diagnoses
o High-flow, low-resistance arterial flow
o Prominent parametrial vessels
• Gestational trophoblastic disease (GTD)
• • Endometrial carcinoma
MR
o Bulky appearance of involved myometrium • Retained products of conception
o Focal or diffuse disruption of junctional zone • Pelvic varicosities
o Multiple, serpentine flow-related signal voids Clinical Issues
o No well-defined mass or margins
• Menometrorrhagia
• MRA
• If AVM not suspected, diagnostic D&C can result in
o Enlarged arteries feeding a vascular network
life-threatening hemorrhage
o Early venous filling

ultrasound (TVUS) shows
multiple small anechoic
spaces in the anterior
myometrium producing
a "spongy" myometrial
echotexture . No distinct
mass could be identified.
Doppler ultrasound shows
more extensive abnormality
than grayscale with a mosaic
pattern of color signals. Color
aliasing is noted due to high
flow velocity in the lesion.
(Left) Transverse pulsed

Doppler ultrasound in the
same patient shows high-
velocity, low-resistance flow
with little variation between
systolic and diastolic velocities,
compatible with a uterine
AVM. (Right) Axial oblique
T2WI FSE MR in the same
patient shows an ill-defined
abnormality containing
multiple signal voids .
The signal voids were due to
blood flow, as confirmed by
their serpentine morphology
and enhancement. MR is
most useful for demonstrating
the extent of the vascular
2 malformation.
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UTERINE ARTERIOVENOUS MALFORMATION
Uterus
o Multiple serpentine flow-related signal voids
TERMINOLOGY o No well-defined mass or margins
Abbreviations o May project into endometrial cavity mimicking
• Uterine arteriovenous malformation (AVM) endometrial polyp
Synonyms
• T1WI C+ FS
o Useful for delineating extent of malformation,
• Cavernous hemangioma treatment planning, and post-embolization follow-
• Cirsoid aneurysm up
• Racemose aneurysm o Complex, serpentine, abnormal vasculature
• Arteriovenous aneurysm enhancing as intensely as normal vessels
• Pulsatile angioma o Prominent parametrial vessels
Definitions
• MRA
o Enlarged feeding arteries supplying a vascular
• AVM network
o Multiple arteriovenous connections between o Early venous filling
intramural arterial branches and myometrial venous
plexus without intervening capillary network Ultrasonographic Findings
• Arteriovenous fistula (AVF) • Grayscale ultrasound
o Abnormal direct communication between an artery o Variable and nonspecific appearance
and vein without intervening capillary network ▪ Multiple, tubular anechoic spaces within
myometrium
– Majority distributed uniformly producing
IMAGING "spongy" myometrial echotexture
– Less commonly anechoic spaces may appear
General Features
• Best diagnostic clue serpentine and branching
– No associated mass effect
o Doppler US
▪ Subtle myometrial inhomogeneity
▪ Mosaic color pattern with aliasing and low-
▪ Visible flow/pulsatility in cystic spaces
resistance, high-velocity flow within abnormal ▪ Generally no soft tissue interposed between
areas of myometrium
vascular spaces
▪ No intervening tissue
▪ Normal-appearing endometrium
o Contrast-enhanced MR
▪ Prominent parametrial vessels
▪ Complex, serpentine, abnormal vessels within o Uncommon sonographic appearances
myometrium ▪ Focal intramural mass resembling leiomyoma
▪ Enlarged feeding artery
▪ Endometrial mass mimicking endometrial polyp
▪ Early venous return
▪ Bulky, enlarged cervix
• Location
• Pulsed Doppler
o Myometrium, localized or more extensive
o High-flow, low-resistance arterial flow
o May protrude into endometrial cavity
▪ Resistive index: 0.1-0.6
• Size ▪ Pulsatility index: 0.3-0.6
o Size of vessels in malformation can vary considerably o Typically high peak systolic velocity (PSV) > 100 cm/
• Morphology second
o Myometrial vascular abnormality ▪ Occasionally lower PSV 20-100 cm/second
o No mass effect ▪ PSV may correlate with need for intervention
o Prominent parametrial vessels o Pulsatile high-velocity venous waveform with little
CT Findings variation in systolic-diastolic velocities
▪ Difficult to differentiate veins from adjacent
• CTA arteries
o Noninvasive modality for diagnosis, evaluation, and
▪ Pelvic veins distal to AVM demonstrate pulsatile
treatment planning
o Dual-phase intravenous CT angiography with 3D flow in contrast to normal monophasic flow
rendering • Color Doppler
o Modality of choice for diagnosis, findings more
▪ Hypervascular, arterial-dominant lesion with large
vascular channels consistent and more extensive than grayscale US
o 2 mosaic patterns of color signals
▪ Early filling of dilated veins diagnostic of AVM
▪ Apparent flow reversal (juxtaposed reds and blues)
MR Findings – Due to adjacent vessels of varying orientation
• T1WI and varying flow directions
o Multiple, serpentine flow-related signal voids ▪ Color aliasing (reds and blues with intervening
o Hemorrhage yellow and white)
▪ Hyperintense areas with mass effect – Due to high-velocity flow
• T2WI o Limited in delineating extent of lesion
o Bulky appearance of involved myometrium • Power Doppler
o Distortion of uterine zonal anatomy with focal or o All cystic spaces fill with flow
diffuse disruption of junctional zone
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Angiographic Findings ▪ More common and typically posttraumatic or

• Historic gold standard for diagnosis postinfectious
▪ Fistulous connection between artery and vein
• Now reserved for transcatheter embolization
• Angiographic findings without network of abnormal vessels
▪ Typically easier to treat with transcatheter arterial
o Complex tangle of vessels
o Hypertrophied feeding uterine arteries (single or embolization due to single feeding artery
o Risk factors
bilateral) ▪ Dilatation and curettage (D&C)
o Early venous drainage in arterial phase of contrast
▪ Intrauterine devices
o Stasis of contrast within abnormal vessels in later
▪ Pelvic surgery (cesarean section or hysterectomy)
phases of contrast ▪ Infection
Imaging Recommendations ▪ GTD
• Protocol advice – Arteriovenous communication due to
o Doppler US modality of choice for initial diagnosis trophoblastic invasion and destruction of
and follow-up (grayscale US in isolation is uterine vessels
insufficient for diagnosis) ▪ Endometrial/cervical carcinoma
o Contrast-enhanced T1WI/MRA for confirmation and ▪ Maternal diethylstilbestrol exposure
assessment of disease extent • Associated abnormalities
o Doppler US coupled with MR imaging can substitute o Uterine artery pseudoaneurysm
for diagnostic angiography ▪ Uterine trauma may result in an AVM,
o Angiography to delineate feeding arteries and pseudoaneurysm, or both
draining veins for treatment planning ▪ Vessels in AVM are susceptible to even minimal
trauma
▪ Imaging findings are similar with the addition of
DIFFERENTIAL DIAGNOSIS anechoic sac/cystic structure on US
Gestational Trophoblastic Disease (GTD) ▪ Equally amenable to transcatheter embolization
• Positive β-hCG Gross Pathologic & Surgical Features
• Overlapping imaging/Doppler features • Congenital AVM
• May coexist with uterine AVM o Multiple feeding arteries and draining veins with
intervening nidus
Endometrial Carcinoma o Commonly have multiple vascular connections
• Neovascularity has low-volume, high-velocity flow within lesion
Retained Products of Conception o Invade surrounding structures such as viscera, skin,
• Positive β-hCG muscle
o Growth in pregnancy
o Uncommonly, β-hCG can be negative with cystic
degeneration of retained products • Acquired AVF
o Single or bilateral feeding uterine arteries
• Endometrial-based mass
o Not supplied by extrauterine arteries
• Can have overlapping Doppler characteristics
o No nidus
Pelvic Varicosities Microscopic Features
• Prominent parametrial vessels with normal venous • Tangle of vessels of varying sizes
• Vessels have characteristics of arteries and veins
spectral waveforms
Uterine Hemangiomas • No intervening capillary network
• Complex mass with acoustic shadowing due to • Disruption of internal elastic lamina
phleboliths
• Prominent intimal fibrous thickening with some
elastin in walls
PATHOLOGY
General Features CLINICAL ISSUES
• Etiology Presentation
o Congenital AVM
▪ Rare
o Menometrorrhagia
▪ Anomalous differentiation of primitive capillary ▪ Intermittent and unexpected
plexus with resultant multiple abnormal ▪ Resistant to treatment
communications between arteries and veins ▪ Can be torrential bleeding, suggestive of arterial
▪ Can be further subclassified based on size of source
intralesional vessels ▪ Up to 30% may require blood transfusion
o Acquired AVF
▪ Hormonal changes may trigger bleeding
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Uterus
– Pregnancy DIAGNOSTIC CHECKLIST
– Menstruation
– High-dose estrogen and progestin Consider
▪ Bleeding often after delivery, miscarriage, or • Consider uterine AVM in patient with vascular uterine
surgical procedures on uterus mass and unexpected bleeding in setting of recent
▪ Bleeding may result from exposure of vessels pregnancy, D&C, or other intervention
following sloughing of endometrium with
menstruation or iatrogenically with curettage Image Interpretation Pearls
▪ Potentially life-threatening hemorrhage with • Doppler US
diagnostic D&C (if AVM not suspected) o Mosaic color pattern with aliasing and low-
o May be asymptomatic and not hemodynamically resistance, high-velocity flow in area of multiple,
significant tubular, anechoic spaces within myometrium
o Usually occur in otherwise healthy individual • CT/MR/angiography
• Other signs/symptoms o Focal uterine vascular network with enlarged feeding
o Lower abdominal pain arteries and early venous filling
o Dyspareunia
o Anemia
SELECTED REFERENCES
o High-output cardiac failure due to vascular steal
1. Aiyappan SK et al: Doppler sonography and 3D
syndrome
o Habitual spontaneous abortion CT angiography of acquired uterine arteriovenous
•
malformations (AVMs): report of two cases. J Clin Diagn Res.
Clinical profile 8(2):187-9, 2014
o Negative serum β-hCG 2. Oride A et al: Disappearance of a uterine arteriovenous
o Refractory menometrorrhagia (requiring blood malformation following long-term administration of
transfusion in 30% of cases) oral norgestrel/ethinyl estradiol. J Obstet Gynaecol Res.
40(6):1807-10, 2014
Demographics 3. Wani NA et al: Uterine arteriovenous malformation
• Age diagnosed with multislice computed tomography: a case
o Typically premenopausal report. J Reprod Med. 55(3-4):166-70, 2010
▪ 20-40 years 4. Brown JV 3rd et al: Contemporary diagnosis and
management of a uterine arteriovenous malformation.
o Rarely postmenopausal
Obstet Gynecol. 112(2 Pt 2):467-70, 2008
Natural History & Prognosis 5. Rufener SL et al: Sonography of uterine abnormalities in
• Potential for life-threatening vaginal bleeding,

postpartum and postabortion patients: a potential pitfall of
interpretation. J Ultrasound Med. 27(3):343-8, 2008
mandating early diagnosis and treatment 6. Maleux G et al: Acquired uterine vascular malformations:
o High index of suspicion to prevent diagnostic D&C radiological and clinical outcome after transcatheter
• In stable patients, expectant management has a role embolotherapy. Eur Radiol. 16(2):299-306, 2006
o Spontaneous resolution is common 7. O'Brien P et al: Uterine arteriovenous malformations: from
diagnosis to treatment. J Ultrasound Med. 25(11):1387-92;
Treatment quiz 1394-5, 2006
• Transcatheter arterial embolization 8. Grivell RM et al: Uterine arteriovenous malformations:
o Allows preservation of fertility a review of the current literature. Obstet Gynecol Surv.
o Must treat uterine arteries bilaterally due to cross 60(11):761-7, 2005
9. Timmerman D et al: Color Doppler imaging is a valuable
filling tool for the diagnosis and management of uterine vascular
▪ Cross filling may not be apparent at initial malformations. Ultrasound Obstet Gynecol. 21(6):570-7,
angiography 2003
o May use Gelfoam, PVA particles, or glue 10. Kwon JH et al: Obstetric iatrogenic arterial injuries of the
o Off-label use of a liquid embolic agent has been uterus: diagnosis with US and treatment with transcatheter
found to be of value as it can be deposited at nidus of arterial embolization. Radiographics. 22(1):35-46, 2002
AVM 11. Nagayama M et al: Fast MR imaging in obstetrics.
o Rare complications due to internal iliac artery Radiographics. 22(3):563-80; discussion 580-2, 2002
12. Nasu K et al: Uterine arteriovenous malformation:
embolization ultrasonographic, magnetic resonance and radiological
▪ Perianal skin sloughing findings. Gynecol Obstet Invest. 53(3):191-4, 2002
▪ Uterovaginal or rectovaginal fistulas 13. Polat P et al: Color Doppler US in the evaluation of uterine
▪ Lower extremity neurologic deficits vascular abnormalities. Radiographics. 22(1):47-53, 2002
• Hysterectomy 14. Huang MW et al: Uterine arteriovenous malformations:
o Definitive treatment if fertility no longer desired gray-scale and Doppler US features with MR imaging
• If asymptomatic, may observe for spontaneous correlation. Radiology. 206(1):115-23, 1998
resolution
• Stable patients without spontaneous resolution may
respond to course of medical therapy
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(Left) Transverse TVUS shows

an endometrial mass with
small internal cystic spaces
. (Right) Transverse color
marked blood flow within
the mass with juxtaposition
of red and blue consistent
with apparent reversal of flow
in an uterine AVM. Rarely,
AVMs may project into the
endometrial cavity mimicking
a polyp.

shows a mass projecting
into the hyperintense
endometrial stripe and
containing punctate signal
voids . (Right) Axial T1WI
C+ FS MR in the early arterial
phase shows serpentine
enhancement within the
mass, as well as an enlarged
left uterine artery . The
serpentine early arterial
enhancement of the mass and
enlargement of the uterine
artery are typical of uterine
AVM.
(Left) TVUS in a patient s/p

recent spontaneous abortion
and D&C shows an anechoic
space , as well as multiple
small anechoic spaces in
the myometrium producing
a "spongy" echotexture
. (Right) Color Doppler
ultrasound shows marked
blood flow in the "spongy"
myometrium with color
aliasing. Blood flow in the
large anechoic space could
not be confirmed with pulse
Doppler interrogation. The
color Doppler abnormalities
of uterine AVMs are typically
much more extensive than the
2 grayscale findings.
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Uterus
in the same patient shows ill-
defined enlargement of the
uterine fundus containing
multiple serpentine flow voids.
(Right) Coronal MIP image
from dynamic MRA in the
arterial phase shows intense
round enhancement centrally
corresponding to the large
anechoic space with a tangle of
surrounding vessels consistent
with pseudoaneurysm and
coexisting uterine AVM. Note
the enlargement of bilateral
uterine arteries and early filling
of bilateral ovarian veins , all
typical angiographic findings of
uterine AVMs.
(Left) In the same patient, frontal

angiographic image of a selective
right uterine artery injection
obtained in the early arterial
phase shows hypertrophy of
the right uterine artery and
opacification of a complex
tangle of vessels . (Right)
Frontal angiographic image of
selective right uterine artery
catheterization obtained later in
the same injection shows early
opacification of the dilated right
ovarian vein and stasis of
contrast in the abnormal tangle
of vessels.
(Left) In the same patient, frontal

angiographic image of a selective
right uterine artery injection
obtained following off-label
use of a liquid embolic agent
shows the enlarged right
uterine artery . However, the
malformation itself no longer
opacifies. (Right) Post-treatment
coronal MIP image from dynamic
MRA in the arterial phase shows
the dilated tortuous right uterine
artery , but no residual
arteriovenous malformation or
pseudoaneurysm. Note absence
of the early draining ovarian
veins.
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Uterus UTERINE ARTERY EMBOLIZATION IMAGING
Key Facts
Imaging Top Differential Diagnoses
• Successful UAE • Leiomyosarcoma
o Coagulative necrosis/hemorrhagic infarction
o Decreased size of uterus and leiomyomas • Leiomyoma autoinfarction
o May have minimal gas in leiomyoma • Endometrial carcinoma
• Failed UAE Clinical Issues
o Residual viable tumor
o No change in size or regrowth of leiomyoma
• Most common symptoms
o Most commonly menorrhagia
• Complications of UAE o Pain and pressure
o Fibroid expulsion (2.5%) o Urinary symptoms
o Infection (< 1%)
o Thromboembolism
•Factors influencing success of UAE
o Nonviable leiomyomas (autoinfarction)
o Nontarget embolization o Uterus or leiomyoma size > 20 cm
o Uterine necrosis o Pedunculated subserosal leiomyoma, stalk < 2 cm
• MR/MRA for pre-UAE evaluation o Large intracavitary leiomyoma
o Leiomyoma size, number, location, and viability o Submucosal leiomyoma
o Identify ovarian-uterine artery anastomoses o Cervical leiomyoma
o Identify alternative and comorbid conditions o Adenomyosis
(Left) Axial T2WI FSE MR in a

patient post UAE shows a large
intramural leiomyoma with
heterogeneous signal intensity.
(Right) Axial T1WI FS MR
shows diffuse increased signal
throughout the leiomyoma
consistent with coagulative
necrosis or hemorrhagic
infarction of the fibroid.

surrounding myometrium
; however, the intrinsic
T1 signal in the leiomyoma
due to hemorrhagic necrosis
makes evaluation for residual
viable tissue difficult. (Right)
Axial T1 C+ subtraction MR is
useful for showing the lack of
internal enhancement in the
leiomyoma and confirming
successful embolization.
Subtraction (postcontrast
minus precontrast) is
helpful both pre and post
embolization if there is any
intrinsic hyperintensity in the
2 leiomyoma.
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UTERINE ARTERY EMBOLIZATION IMAGING
Uterus
TERMINOLOGY – Complex cystic adnexal mass with thick
enhancing wall/septations and surrounding
Abbreviations inflammation
• Uterine artery embolization (UAE) ▪ Pyomyoma
– Gas in leiomyoma is not diagnostic of infection
Synonyms as it can be normally seen post procedure
• Uterine fibroid embolization (UFE) o Thromboembolism
▪ Deep venous thrombosis (0.25%)
Definitions
▪ Pulmonary embolism (PE) (0.25%)
• Pre-UAE imaging o Nontarget embolization
o To define anatomy and select appropriate patients
▪ Ovarian dysfunction (premature menopause)
• Post-UAE imaging – Increased risk in women > 45 years of age due to
o To assess response and evaluate for complications
increased uterine-ovarian artery anastomoses
(43%)
IMAGING – Women < 45 years of age have < 5% prevalence
of anastomoses
General Features ▪ Urinary bladder necrosis
• Best diagnostic clue o Uterine necrosis
o Successful UAE ▪ Lack of uterine enhancement post contrast
▪ Coagulative necrosis/hemorrhagic infarction ▪ Requires hysterectomy in < 1%
– ↑ T1, no enhancement o 2 reported deaths due to septicemia and PE
▪ Decreased size of uterus and leiomyomas
– 40-60% decrease in uterine volume
CT Findings
– 40-70% decrease in dominant leiomyoma • CECT
o Successful UAE
volume
▪ May have minimal gas in leiomyoma ▪ Infarcted leiomyomas do not enhance
– Gas fills potential spaces left by tissue infarction/ ▪ High attenuation due to hemorrhagic infarction
desiccation ▪ Minimal gas can be normally seen
– Can be seen as early as 1 month post UAE ▪ Rim calcification may occur (> 6 months post
– Does not imply infection procedure)
o Failed UAE o Failed UAE
▪ Residual viable tumor ▪ Residual viable enhancing leiomyoma tissue
o CT not helpful pre-UAE for patient selection or
– Internal enhancement
▪ No change in size or regrowth of leiomyoma anatomic localization
• Imaging is important before and after UAE MR Findings
o Pre-UAE imaging
▪ Patient selection
• T1WI
o Successful UAE
▪ Define uterine anatomy and arterial supply ▪ ↑ signal intensity (SI) indicative of coagulative
▪ Prediction of success (hemorrhagic) necrosis due to methemoglobin
▪ Prediction of risk of complications ▪ Variable SI if leiomyoma is not liquified
o Post-UAE imaging – ± foci of susceptibility artifact due to gas
▪ Surveillance o Failed UAE
▪ Evaluate complications ▪ Leiomyoma isointense to myometrium
• Complications of UAE •T2WI
o Minor (require mild supportive care) o Successful UAE
▪ Puncture site hematoma ▪ Variable depending on age of hemorrhage
▪ Urinary retention – ↓ SI in necrotic leiomyomas not yet liquefied
▪ Transient pain – Progressive liquefaction with time with
▪ Transient vessel or nerve injury at puncture site increasing SI
o Fibroid expulsion (2.5%) o Failed UAE
▪ Occurs with submucosal/intracavitary fibroids ▪ Heterogeneous depending on degree of necrosis
▪ Usually well tolerated; may have cramping, pain,
•T1WI C+
possible infection with large fibroids o Successful UAE
▪ Rarely, may obstruct cervix, require hysteroscopic ▪ No internal enhancement if completely infarcted
resection, or hysterectomy o Failed UAE
▪ Imaging will show necrotic leiomyoma extending ▪ Incompletely infarcted leiomyomas have variable
into and passing through endocervical canal degrees of enhancing tissue
o Infection (< 1%)
▪ Residual viable tissue may result in failure due to
▪ Prolonged/recurrent pain and fever regrowth of leiomyoma
▪ If refractory to antibiotics, may require
percutaneous drainage or surgery
•MRA
o Helpful for defining arterial anatomy and collateral
▪ Endometritis (0.5%)
circulation
– Clinical diagnosis, imaging is nonspecific
▪ Pelvic inflammatory disease
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▪ Collateral arterial supply to leiomyoma from ▪ Monitor treatment response

ovarian artery may lead to incomplete or ▪ Evaluate potential complications (identify
nondurable results intracavitary sloughed leiomyomas, identify
▪ Collateral arterial supply to ovary from uterine presence of viable uterine attachment of passing
artery may lead to nontarget embolization with leiomyoma)
early menopause o MR provided considerable additional information
• Important to recognize autoinfarction pre-UAE because compared with US and affected clinical decision
these patients are unlikely to benefit from UAE making in 1 institution study
o ↑ T1, heterogeneous T2, no enhancement • Protocol advice
o Leiomyomas are common, need to look for other
• Grayscale ultrasound conditions possibly causing symptoms
o T2WI MR in at least 2 orthogonal planes (sagittal and
o Ultrasound is limited in evaluating efficacy of UAE
short axis) to localize leiomyomas
due to lack of reproducible method of evaluating o T1WI FS MR pre- and post-contrast to assess viability
perfusion o Dynamic high-resolution MRA
o Decrease in uterine and leiomyoma size and volume
o Dominant leiomyoma may no longer be visualized
o Fetal head sign DIFFERENTIAL DIAGNOSIS
▪ Hyperechoic rim of peripheral calcification around
Leiomyosarcoma
• No specific imaging findings
hypoechoic fibroid
▪ Seen 6-12 months post UAE
• Color Doppler • Suggestive findings
o 44% ↓ in vascularity compared to myometrium o Irregular shape, ill-defined margins, internal necrosis
o May show collateral flow in treatment failures o Growth after embolization
o Evidence of metastatic disease
• Vessels to leiomyomas embolized to near stasis with Leiomyoma Autoinfarction
preservation of main uterine artery trunk • Commonly occurs during pregnancy
• Arterial collaterals may be too small to detect but o Estrogen promotes leiomyoma growth
o Leiomyoma may outgrow blood supply and infarct
may be visible following embolization due to flow
redistribution o May cause acute pain
• Utero-ovarian anastomoses in 10-30% Endometrial Carcinoma
• Types of ovarian-to-uterine artery anastomoses
• Usually postmenopausal female with abnormal
o Type 1a: Ovarian artery connects to intramural bleeding
uterine artery before leiomyoma supply via tubo- • Ill-defined margins invading myometrium
ovarian segment
▪ Flow in tubal artery is toward uterus, without
• Homogeneously hyperintense on T2WI
retrograde reflux into ovary
o Type 1b: Ovarian artery connects to intramural PATHOLOGY
uterine artery before leiomyoma supply via tubo-
ovarian segment Gross Pathologic & Surgical Features
▪ Flow in tubal artery is toward uterus, with • Soft on sectioning; may be pale if hyaline degeneration
retrograde reflux into ovary (may predispose to Microscopic Features
ovarian failure)
o Type 2: Ovarian artery supplies leiomyoma • Hyaline degeneration
• Massive necrosis
• Dystrophic calcification
directly, without connection to uterine artery (may
predispose to treatment failure)
o Type 3: Uterine arterial supply to ovary via tubo- • Vascular thrombosis
ovarian segment (may predispose to ovarian failure) • Intravascular foreign material: Histiocytic and giant cell
• Round ligament (branch of inferior epigastric or reaction
external iliac artery) is rarely a source of collateral • Less embolic material located in leiomyomas that fail to
supply respond to UAE
• Best imaging tool CLINICAL ISSUES
o MR/MRA for pre-UAE evaluation
Presentation
▪ Diagnose leiomyoma to include size, number,
location, and viability
o Most common symptoms prompting UAE
▪ Identify ovarian-uterine artery anastomoses
▪ Most commonly menorrhagia
▪ Identify alternative and comorbid conditions
o MR/MRA for post-UAE ▪ Pain and pressure
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Uterus
▪ Urinary symptoms (frequency or rarely • Absolute contraindications
hydronephrosis) o Pregnancy
o Immediately post procedure o Gynecologic malignancy
▪ Most patients have moderate pain due to ischemia o Active uterine/adnexal infection
– Peak pain 24-48 hours post-UAE • Relative contraindications
– Opioids and NSAIDs for pain management o Contrast material allergy
– Lack of pelvic pain immediately following UAE o Coagulopathy
can be indication of failure o Renal failure
▪ Postembolization syndrome
– Occurs commonly, severe in 34%, results in Natural History & Prognosis
readmission in 10% • > 25,000 procedures performed worldwide
– Fatigue, anorexia, nausea, vomiting, malaise o Improvement in health-related quality of life
– 1/3 present with low-grade fever o Improvement in leiomyoma-specific symptoms
•Clinical profile ▪ Bleeding (menorrhagia, menometrorrhagia):
o Pre-UAE: Patient selection 81-100%
▪ Gynecologic evaluation ▪ Bulk-related symptoms: 64-96%
▪ Assess whether symptoms are attributable to ▪ Fibroid-induced hydronephrosis usually resolves
leiomyomas, warrant treatment o Shorter hospital stay compared with hysterectomy
▪ Pre-UAE predictors of success: Hypervascularity, (1.71 vs. 5.85 days)
submucosal location, and smaller size o Anecdotal reports of successful pregnancy post UAE
▪ Identify patients that may be better served by other • Technical success rate: 84-100%
therapies • Clinical success rate: 85-90%
– Hysteroscopic resection for pedunculated • Long-term (5-year) outcome
submucosal leiomyomas o 73% with continued symptom control
– Myomectomy for large pedunculated subserosal o Long-term failure more likely in women not
leiomyomas improved at 1 year
– Hysterectomy for massively enlarged uterus (> • Complications
22-24 cm in length) o Society of Interventional Radiology (SIR)
o Post-UAE: Surveillance ▪ 8.5% short-term complication rate
▪ Imaging not necessary if asymptomatic ▪ 1.25% serious complication rate
▪ Useful to assess for residual viability, passage, or o Estimated mortality rate: 2 per 10,000 cases
complications
•Factors influencing success of UAE
o Nonviable leiomyomas (autoinfarction)
▪ Devascularized, therefore unlikely to ↓ in size or Image Interpretation Pearls
result in symptom relief
o Uterus or leiomyoma size > 20 cm • Successful UAE
o Coagulative necrosis with ↑ T1, variable T2, no
▪ Less likely to have fibroid shrinkage, symptom
enhancement
relief, and long-term satisfaction o ± gas in leiomyoma
o Subserosal leiomyoma
o Decrease in uterine and leiomyoma volume with
▪ Pedunculated
time
– Potential for stalk necrosis and detachment
– ± peritonitis, pain, infection • Failed UAE
o Residual viable (enhancing) leiomyoma tissue
– Stalk diameter ≥ 2 cm not associated with
increased risk of serious complications Reporting Tips
▪ If large, may parasitize extrauterine vessels and lead • Uterine size and volume
to treatment failure
o Large intracavitary leiomyoma • Leiomyoma size and volume (report largest)
▪ Increased risk of fibroid expulsion • Leiomyoma location, number, viability, stalk diameter
o Submucosal leiomyoma • Arterial anatomy; collateral supply to fibroid or ovary
▪ Expulsion of fragments occurs in 10% • Other uterine or adnexal pathology
– Less common in nulliparous females
– Up to 50% if diameter > 5 cm or volume > 66 mL SELECTED REFERENCES
▪ Submucosal leiomyoma may become intracavitary
– ↑ ratio → ↑ risk of becoming intracavitary 1. Bulman JC et al: Current concepts in uterine fibroid
embolization. Radiographics. 32(6):1735-50, 2012
– Ratio of largest leiomyoma endometrial interface
to largest leiomyoma dimension leiomyomas before and after embolization. Radiographics.
o Cervical leiomyoma 32(6):E251-81, 2012
▪ Tends to be resistant to complete infarction, 3. Kroencke TJ et al: Uterine artery embolization for
thought to be due to additional blood supply leiomyomas: percentage of infarction predicts clinical
o Adenomyosis outcome. Radiology. 255(3):834-41, 2010
▪ Some studies report decreased rate of UAE success 4. Ghai S et al: Uterine artery embolization for leiomyomas:
▪ Helpful to know when counseling patient pre- and postprocedural evaluation with US. Radiographics.
preprocedure
25(5):1159-72; discussion 1173-6, 2005
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shows a large leiomyoma
in the posterior uterine
fundus/body. There is also
thickening of the junctional
zone anteriorly, compatible
with coexisting adenomyosis.
(Right) Coronal oblique T2WI
shows multiple leiomyomas
and confirms adenomyosis
. It is important to identify
adenomyosis on the pre-
UAE MR so that the patient
may be counseled regarding
the decreased likelihood of
success.
(Left) Axial T2WI FSE

MR shows a hypointense
leiomyoma arising from the
right lower uterine segment
. Although subserosal in
location, the fibroid has a
broad-based attachment to
the uterus and can be safely
embolized. Pedunculated
subserosal leiomyomas with
a stalk diameter < 2 cm
are at risk for detachment
from the uterus following
embolization. (Right) Axial
T1WI C+ FS MR shows nearly
homogeneous enhancement
of the leiomyoma , further
confirming suitability for UAE.

the same patient performed
3 months post embolization
shows the typical findings of
decreased signal and size of
the leiomyoma . (Right)
Axial T1WI C+ FS MR shows
absence of enhancement in
the fibroid compatible
with successful infarction. The
degree of leiomyoma infarction
is the best predictor of success.
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Uterus
in a patient post UAE shows a
leiomyoma in the uterine
cavity extending into the
endocervical canal. (Right)
Sagittal T1WI C+ FS MR in the
same patient shows complete
absence of enhancement of
the fibroid compatible with
infarction. Localizing fibroids
pre-UAE is important so that
the patient may be counseled
on the possibility of expelling
submucosal fibroids following
embolization. Most leiomyomas
pass uneventfully; however, large
fibroids may obstruct the cervix,
become infected, and require
surgery.

shows a large, circumscribed,
hypointense intramural
leiomyoma . (Right) Axial
T1WI C+ FS MR shows
of the leiomyoma . It is
important to give intravenous
contrast when performing MR for
pre-UAE evaluation to determine
the viability of the fibroids.
Success is unlikely if there is
little or no enhancement of the
fibroids, and other treatment
options such as myomectomy
or hysterectomy should be
considered.

the same patient post UAE
shows slight decrease in size of
the fibroid and mild increased
signal centrally. (Right) Axial
T1WI C+ FS MR shows central
necrosis , but persistent
thick rim enhancement of
the leiomyoma consistent with
residual viable tissue. Incomplete
infarction is associated with
regrowth of the fibroid and
recurrence of symptoms. Over
90% infarction, as estimated on
MR, correlates with significantly
better symptom control and
lower reintervention rate.
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Uterus TAMOXIFEN-INDUCED CHANGES
Key Facts
Terminology • TVUS for initial imaging
• Proliferative response of endometrium to selective • SHG should be performed if TVS is nondiagnostic, or
estrogen receptor (SERM) therapy there is nonspecific endometrial thickening

• Endometrial thickening with cystic change • Endometrial abnormalities unrelated to tamoxifen
o Endometrial polyps, hyperplasia, cystic atrophy, and • Metastatic breast cancer
carcinoma • Submucosal leiomyoma
Clinical Issues
o Adenomyosis
o Ovarian cysts • Most commonly asymptomatic
o Enlargement of leiomyomas • Abnormal uterine bleeding
• ACOG does not recommend imaging screening of • Up to 50% develop abnormalities by 36 months
asymptomatic women on tamoxifen
• Abnormal vaginal bleeding should be investigated
• Consider tamoxifen-induced change in a patient with
o ET > 5 mm in postmenopausal women is abnormal
o Focal endometrial thickening, mass, or breast cancer and endometrial abnormality
heterogeneity is abnormal • Must always consider endometrial cancer or metastatic
breast cancer in differential diagnosis

MR in a patient with breast
cancer on tamoxifen shows
punctate subendometrial
hyperintensities with a thin
endometrial stripe compatible
with cystic atrophy. Incidental
note is made of nabothian
cysts and C-section scar
. (Right) Coronal oblique
patient shows the punctate
subendometrial cysts as
well as a larger cyst . Cysts
in the ovaries are also
associated with tamoxifen
therapy.

ultrasound in a patient on
tamoxifen shows well-defined
echo complex (28 mm)
with multiple anechoic cysts
same patient shows a single
feeding vessel to the
thickened cystic endometrium,
suggesting a vascular stalk
and an endometrial polyp as
the cause of the endometrial
abnormality. Hysteroscopic
biopsy and removal can be
performed to exclude the small
risk of endometrial carcinoma.
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TAMOXIFEN-INDUCED CHANGES
Uterus
TERMINOLOGY ▪ Echogenic focal endometrial thickening or mass
▪ ± cysts, ± vascular pedicle
Definitions ▪ Tend to be larger than those in general population;
• Proliferative response of endometrium to selective mean diameter: 5 cm
o Endometrial hyperplasia
estrogen receptor (SERM) therapy
▪ Well-defined endometrial thickening ± cysts
o Cystic endometrial atrophy
IMAGING ▪ Irregular cystic endometrium; may lead to
General Features spuriously thickened endometrial measurement
▪ Cysts tend to be subendometrial in location
• Best diagnostic clue o Adenomyosis
o Endometrial thickening with cystic change
▪ Heterogeneous myometrium
▪ Nonspecific and may represent
▪ Myometrial cysts
– Endometrial hyperplasia
▪ Poor endometrial definition
– Endometrial polyp
o Endometrial cancer
– Cystic endometrial atrophy
▪ Endometrial thickening may be well defined or ill
– Endometrial cancer
o Tamoxifen-induced abnormalities may coexist with defined
▪ Diffusely or partially echogenic endometrium
▪ Adenomyosis
▪ Ovarian cysts • Sonohysterography (SHG)
o Polyp: Echogenic mass, smooth margins, most with
▪ Enlargement of leiomyomas
• Cutoff value for normal endometrial thickness (ET) in cystic spaces
o Hyperplasia: Diffuse endometrial thickening, less
asymptomatic women on tamoxifen is controversial
o ACOG does not recommend imaging screening of commonly focal
o Cystic atrophy: Small subendometrial cystic spaces
asymptomatic women on tamoxifen
o ET is > 8 mm in 1/2 of postmenopausal women on o Adenomyosis: Small inner myometrial cysts
o Cancer: Irregular heterogeneous mass or focally
tamoxifen; most are asymptomatic
o Cutoff values between 4-10 mm yield sensitivity of thickened endometrium
85-100% and specificity of 56-96% Imaging Recommendations
• Abnormal vaginal bleeding should be investigated
o Endometrial thickness > 5 mm in postmenopausal o Transvaginal ultrasound (TVUS) for initial imaging
women is abnormal o SHG should be performed if TVUS is nondiagnostic,
o Focal endometrial thickening, mass, or heterogeneity
or there is nonspecific endometrial thickening
are abnormal ▪ Differentiates diffuse vs. focal endometrial
o If endometrium is not entirely visualized, consider
abnormality
SHG ▪ Women on tamoxifen may require cervical dilation
MR Findings for SHG
o MR only if unable to perform SHG
• Endometrial polyp ▪ 8-37% SHG failure rate for postmenopausal women
o MR may be normal
o on tamoxifen
•
Focal endometrial thickening or intracavitary mass
o Protocol advice
T1WI: Isointense, ± hemorrhagic foci
o o Oral analgesics may be given prior to SHG to decrease
T2WI: Slightly hypointense to endometrium, ± cysts,
± fibrous core discomfort
• Endometrial hyperplasia
o MR may be normal DIFFERENTIAL DIAGNOSIS
o Diffuse widening of endometrium
o T2WI: Isointense or slightly ↓ signal intensity (SI) to Endometrial Abnormalities Unrelated to
normal endometrium Tamoxifen
• Cystic atrophy • Endometrial atrophy, hyperplasia, polyp, and
o Thin, smooth, uniform endometrium carcinoma
o ± small cystic changes (↑ T2, no enhancement) • Cannot be distinguished on imaging from tamoxifen-
• Adenomyosis induced abnormalities
o T2WI: Focal or diffuse widening of junctional zone ≥
Metastatic Breast Cancer
12 mm
o ↑ SI foci on T1 and T2 in adenomyotic tissue • Endometrial thickening ± myometrial invasion
• Endometrial cancer • Need biopsy to distinguish from tamoxifen change
o May not be visible on MR Submucosal Leiomyoma
o May be indistinguishable from a benign polyp, • Hypoechoic with shadowing
hyperplasia, or atrophy
o Myometrial invasion is diagnostic
• Easily differentiated on MR with ↓ SI on T2WI
o Endometrial polyp
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PATHOLOGY ▪ If tamoxifen must be continued, consider

hysterectomy
General Features o Cancer: Treatment appropriate to stage of disease
• Etiology
o Antiestrogen that binds to estrogen receptors
o May have paradoxical effects at uterine level
• Associated abnormalities Consider
o Ovarian cysts • Tamoxifen-induced change in a patient with breast
• Spectrum of endometrial abnormalities cancer and endometrial abnormality
o Up to 50% of women develop abnormalities • Must always consider endometrial cancer or metastatic
o Polyps in 8-36% breast cancer
o Hyperplasia in 1.3-20%
o Cystic atrophy
o Adenomyosis • Endometrial thickening ± cystic change
o Carcinoma • Cysts are small, may be beyond resolution of MR
▪ 1.3-7.5x increase in risk • If there is clinical concern, consider further evaluation
▪ Increased risk with duration of tamoxifen use > 3 despite negative MR
years or patient age > 35 years
Gross Pathologic & Surgical Features SELECTED REFERENCES
• Polyps: Large, mean diameter of 5 cm, may have stalk 1. Chen JY et al: Endometrial cancer incidence in breast cancer
• Cystic atrophy: Smooth, white, hypervascularized patients correlating with age and duration of tamoxifen use:
a population based study. J Cancer. 5(2):151-5, 2014
endometrium
• Cancer: Often polypoid morphology 2. Kazerooni T et al: The value of transvaginal ultrasonography
in the endometrial evaluation of breast cancer patients
using tamoxifen. Med Princ Pract. 19(3):222-7, 2010
Microscopic Features
• Polyps: Combination of proliferative activity, aberrant
3. Polin SA et al: The effect of tamoxifen on the genital tract.
Cancer Imaging. 8:135-45, 2008
epithelial differentiation, and focal periglandular 4. Garuti G et al: Pretreatment and prospective assessment
stromal condensation of endometrium in menopausal women taking tamoxifen
• Hyperplasia: Morphologically abnormal proliferative- for breast cancer. Eur J Obstet Gynecol Reprod Biol.
type endometrium ± cytologic atypica and ± cystic 132(1):101-6, 2007
dilation of glands 5. Fishman M et al: Changes in the sonographic appearance
• Cystic atrophy: Cysts lined by atrophic endometrium of the uterus after discontinuation of tamoxifen therapy. J
•
Ultrasound Med. 25(4):469-73, 2006
Adenomyosis: Heterotopic endometrial glands and 6. Duffy S et al: The ATAC ('Arimidex', Tamoxifen, Alone or
stroma in myometrium with surrounding smooth in Combination) adjuvant breast cancer trial: baseline
muscle hypertrophy/hyperplasia endometrial sub-protocol data on the effectiveness of
• Cancer: Most are endometrioid adenocarcinomas transvaginal ultrasonography and diagnostic hysteroscopy.
Hum Reprod. 20(1):294-301, 2005
7. Develioglu OH et al: The endometrium in asymptomatic
CLINICAL ISSUES breast cancer patients on tamoxifen: value of transvaginal
ultrasonography with saline infusion and Doppler flow.
Presentation Gynecol Oncol. 93(2):328-35, 2004
• Most common signs/symptoms 8. Markovitch O et al: The value of sonohysterography in the
o Most commonly asymptomatic prediction of endometrial pathologies in asymptomatic
o Abnormal uterine bleeding postmenopausal breast cancer tamoxifen-treated patients.
• Clinical profile
Gynecol Oncol. 94(3):754-9, 2004
9. Markovitch O et al: The value of transvaginal
o Breast cancer patient or high-risk woman receiving ultrasonography in the prediction of endometrial
tamoxifen pathologies in asymptomatic postmenopausal breast cancer
tamoxifen-treated patients. Gynecol Oncol. 95(3):456-62,
Demographics 2004
• Epidemiology 10. Fong K et al: Transvaginal US and hysterosonography
o Up to 50% develop abnormalities by 36 months in postmenopausal women with breast cancer receiving
tamoxifen: correlation with hysteroscopy and pathologic
Natural History & Prognosis study. Radiographics. 23(1):137-50; discussion 151-5, 2003
• Endometrium may remain thickened for 6-12 months 11. Fung MF et al: Prospective longitudinal study of ultrasound
following discontinuation of tamoxifen therapy screening for endometrial abnormalities in women
• Controversy over whether tamoxifen-induced with breast cancer receiving tamoxifen. Gynecol Oncol.
91(1):154-9, 2003
carcinomas are more aggressive than those in general
12. Ascher SM et al: Tamoxifen-induced uterine abnormalities:
population
the role of imaging. Radiology. 214(1):29-38, 2000
Treatment
• American College of Obstetricians and Gynecologists
recommendations
o Polyp: Remove
o Atypical hyperplasia: Discontinue tamoxifen and
2 perform dilatation and curettage (D&C)
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Uterus
woman with breast cancer
undergoing tamoxifen therapy
shows tiny anechoic spaces
in the endometrium. The
endometrial stripe is not
thickened, measuring < 5 mm.
shows to better advantage
the typically subendometrial
location of the cysts in cystic
endometrial atrophy.

shows slightly hypointense
diffuse thickening of the
endometrium . Apparent
focal thickening of the
anterior junctional zone was
not confirmed on additional
sequences, compatible with
myometrial contraction.
endometrial thickening with
punctate hypointense foci
compatible with cystic change
in endometrial hyperplasia.
Tiny endometrial cysts are often
difficult to resolve on T2WI and
are better visualized following
intravenous contrast.

ultrasound in a patient with
breast cancer and 4 years of
tamoxifen treatment shows
cystic endometrial thickening
. Sonohysterography can be
useful in differentiating diffuse
hyperplasia or a focal polyp to
further guide biopsy technique
and treatment. (Right) Transverse
sonohysterogram in the same
patient shows a pedunculated
polypoid echogenic mass
with internal cystic change.
Hysteroscopic removal was
performed, and pathology was
consistent with an endometrial
polyp.
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(Left) Transverse TVUS in a

patient with breast cancer
undergoing tamoxifen therapy
shows 2 endometrial polyps
in the background of diffuse
endometrial hyperplasia. There
is echogenic thickening of the
endometrial stripe with subtle
morphology of 2 oval masses
. There are punctate cystic
endometrial foci peripheral
to the polyps. (Right) Coronal
TAS of the uterus shows the
vascular pedicle of 1 of the
polyps.
(Left) Longitudinal TVUS in the

same patient shows a cystic
adnexal mass with low-
level internal echoes and a
mural nodule with cystic
change. Endometrial tissue in
an endometrioma can also be
influenced by tamoxifen and
parallel the changes seen in
the endometrium. (Right) Axial
T2WI FSE MR shows the low-
signal fibrovascular stalk of
1 polyp, which corresponds
to Doppler flow typically seen
on sonography. The punctate
cysts in the endometrium are
often beyond the resolution of
T2WI and are more often seen
on postcontrast sequences.
(Left) Axial oblique T2WI

FSE MR shows T2 shading in
the cystic left adnexal mass
as demonstrated by the
hypointense fluid level .
The cystic change in the
mural nodule parallels
the similar changes induced
in the endometrium by
tamoxifen. (Right) Axial T1 C
+ subtraction MR shows to
better advantage the diffuse
cystic dilation of endometrial
glands characteristic of
endometrial hyperplasia
as well as the absence of
significant enhancement in the
endometrioma .
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Uterus
ultrasound shows cystic
thickening of the endometrium
in this patient on tamoxifen
for breast cancer. This
appearance is nonspecific and
may be seen with an endometrial
polyp, hyperplasia, cystic
atrophy, or endometrial cancer.
The latter is unlikely in the
absence of abnormal vaginal
bleeding. (Right) Longitudinal
transvaginal ultrasound shows
a left adnexal cyst . Cystic
structures along the periphery
of the dominant cyst represent
cumuli oophori.

was obtained for evaluation
of bone lesions in this patient
with breast cancer. Incidental
note is made of a hypointense
pedunculated endometrial mass
with internal cystic change
. (Right) Longitudinal color
Doppler ultrasound shows the
and small cyst . Transvaginal
ultrasound is often limited
in its ability to differentiate
diffuse and focal abnormalities
of the endometrium.
Sonohysterography has been
shown to improve sensitivity
and specificity of TVUS and
endometrial biopsy.
(Left) Longitudinal color Doppler

ultrasound shows diffuse
stripe measuring 16 mm.
ultrasound shows an adnexal
cyst with multiple small cysts
along its periphery. These
represent cumuli oophori and
localize the dominant cyst to
the ovary, as well as confirm
that this large cyst is physiologic.
Ovarian cysts are more common
in women on tamoxifen therapy
and thought to be due to its
estrogenic effect on the ovary.
2
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Uterus CONTRACEPTIVE DEVICE EVALUATION
Key Facts
Terminology • Complications
• 2 types of IUDs in United States o Displacement (25%), uterine expulsion (10%),
o Copper-containing embedment (18%), complete perforation (0.1%)
o Levonorgestrel-releasing • Essure
• Transcervical tubal occlusion device (Essure) o < 50% of inner coil should be in uterine cavity
o Uterine end of inner coil should be ≤ 30 mm into
o Permanent tubal obstruction
o Inner and outer coils with radiopaque end markers tube from contrast-filled cornua
o Contrast should not fill tube past tubal end of outer
Imaging coil
• US o Complications: Tubal patency, central migration,
o IUD stem is linear bright echo aligned with distal placement
endometrial cavity
o Arms/cross bars extend laterally at fundus Top Differential Diagnoses
o If difficult to visualize, look for shadowing • Air in uterine cavity due to attempted placement
• MR • Retained products of conception
o IUD is signal void on all sequences • Dystrophic endometrial calcifications
• KUB helps to differentiate IUD expulsion from • Bright echo of normal interface of endometrial lining
perforation • Arcuate artery calcifications

ultrasound shows the
echogenic stem of the
IUD well positioned in the
uterine cavity. The IUD can
normally be up to 3 mm from
the fundal endometrium.
(Right) 3D ultrasound image
shows the arms and stem
of the IUD relative to
the uterine cavity. This IUD
is well positioned without
embedment. The copper IUDs
are typically echogenic.
(Left) Graphic shows the

Essure device appropriately
positioned at the uterotubal
junction. There are 2
overlapping coils, each with
radiopaque end markers.
Greater than 50% of the inner
coil should be in the tube. The
expansile outer coil conforms
to the tube and can vary in
length. (Right) Scout image
for HSG shows bilateral Essure
tubal occlusion devices. Note
2 radiopaque markers at the
tubal end and 2 markers
at the uterine end of each
device.
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CONTRACEPTIVE DEVICE EVALUATION
Uterus
TERMINOLOGY IMAGING
Abbreviations General Features
• Intrauterine device (IUD) • IUD
• Intrauterine contraceptive device (IUCD) o US
• Bilateral tubal ligation (BTL) ▪ Longitudinal image
• Levonorgestrel-releasing intrauterine system (LNG-IUS) – IUD stem is straight and aligned with
endometrial cavity
Definitions – ≤ 3 mm between top of IUD and fundal
• IUD endometrium
o Device inserted into endometrial cavity to prevent – Copper IUD is echogenic and easily seen as linear
pregnancy bright echo
o T-shaped polyethylene frame with polyethylene – Levonorgestrel-containing IUD is harder to see,
monofilament string often seen as shadowing between echogenic
o 2 types of IUDs in United States proximal and distal ends
▪ Copper-containing (Paragard, Ortho-McNeil ▪ Transverse image
Pharmaceutical, Inc., Raritan, NJ) – IUD arms/cross bars extend laterally at fundus
– Copper wire wrapped around stem ▪ String may be seen as linear bright echo in cervix
– Works for up to 10 years ▪ Plastic IUDs have entrance-exit echoes in all scan
▪ Levonorgestrel-releasing (Mirena, Shering, AG planes
Pharmaceutical, Germany) ▪ Lippes loop IUD is seen in longitudinal plane as
– Levonorgestrel-containing collar around stem interrupted bright areas with shadowing
– Works up to 5 years o Radiography
o Other IUDs ▪ Copper IUD is radiopaque and well seen
▪ Plastic IUDs and Lippes loop IUD (older) ▪ Levonorgestrel-containing IUD is radiopaque due
▪ Round IUD of stainless steel ring in fundus with to barium sulfate-laden frame
straight shaft in lower endometrium (commonly ▪ Differentiates expulsion from perforation when
used in China) IUD is not seen in uterus on US
o Mechanism of action: Primarily prevents fertilization ▪ Perforation
▪ Induce endometrial and fallopian tube chronic – IUD above pelvic brim
inflammatory change – IUD far lateral or anterior/posterior
– Spermicidal effects – 90° or 180° rotation of IUD is less specific
– Inhibits fertilization o CT
– Inhospitable environment for implantation ▪ Helpful to evaluate for complications related to
▪ Partially inhibit ovulation (Mirena only) perforation and intraabdominal IUD
▪ Copper devices ↑ copper levels → change in ▪ All IUDs are radiopaque
cervical mucus, affecting sperm motility and o MR
irritating endometrium ▪ IUD is signal void on all sequences
• Transcervical tubal occlusion device ▪ May be better seen on T1WI due to accentuated
o Device/material inserted hysteroscopically into susceptibility artifact
fallopian tubes for permanent sterilization •Essure
o Essure (Conceptus Inc., Mountain View, CA) o HSG 3 months post procedure to confirm
▪ 2 overlapping coils each with radiopaque end appropriate position and tubal occlusion
markers ▪ If well positioned, but without tubal occlusion,
– Outer coil made of nitinol (nickel and titanium should continue alternative contraception and
alloy) repeat HSG in 3 months
– Inner coil made of stainless steel wrapped in o 4 markers at ends of 2 overlapping coils
polyethylene terephthalate (PET) fibers ▪ Markers at tubal ends of coils (lateral or distal) are
– Outer coil expands upon release and conforms to fixed relative to each other
tube wall ▪ Markers at uterine ends of coils (medial or
– 4 cm in length proximal) are at variable distances to each other
– 1.5-2 mm expanded diameter due to flexibility of outer coil
▪ PET fibers elicit benign tissue ingrowth around and o HSG
into device ▪ Required in United States to confirm placement
– Anchors device in place and tubal occlusion
– Permanently obstructs fallopian tubes ▪ Tubal end (distal/lateral) of inner coil should be in
o Adiana (Hologic, Bedford, MA) tube
▪ Hysteroscopic focal radiofrequency ▪ < 50% of inner coil should trail into uterine cavity
thermocoagulation of fallopian tube isthmus ▪ Uterine end (proximal/medial) of inner coil should
followed by intraluminal insertion of silicon be ≤ 30 mm into tube from contrast-filled cornua
elastomer matrix ▪ Contrast should not fill tube past tubal end (distal/
lateral) of outer coil
o MR
▪ Linear signal void at uterotubal junction
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▪ Associated blooming may mimic uterine/tubal DIFFERENTIAL DIAGNOSIS

perforation
o CT Retained Products of Conception
▪ Linear radiopaque structure at uterotubal junction • Mass with calcifications
▪ Unable to confirm intraluminal position due to
inability to see fallopian tube
• Calcifications are not linear like IUD
o US Normal Interface of Endometrial Lining
▪ Linear echogenic structure at uterotubal junction • Very thin echogenic area at endometrial interface
▪ Helical outer coil may appear as multiple, parallel, without shadowing
short, linear echoes Dystrophic Endometrial Calcifications
• Adiana
• Punctate or oblong calcifications at endometrial
o Perform HSG at 3 months to confirm tubal occlusion
myometrial interface
▪ Silicone matrix is not radiopaque
▪ ≤ 10 mm of proximal tube may normally opacify Arcuate Artery Calcifications
at HSG • In outer 1/3 of myometrium
▪ > 10 mm of tubal opacification without spill into
peritoneum requires confirmatory US showing Air in Uterine Cavity
matrix is lateral to opacified segment • Nonlinear echogenicity in uterine cavity
o US • Due to attempted IUD placement or other
▪ Silicone matrix is echogenic instrumentation
▪ Typically placed at uterine cornua, but may be
located more laterally CLINICAL ISSUES
Imaging Recommendations Presentation
• Best imaging tool • IUD
o Transvaginal ultrasound for IUD position
o Pain and abnormal bleeding is common within first
o KUB for IUD expulsion/perforation
few months of placement
o HSG for tubal occlusion devices
o Indications for imaging
• Protocol advice ▪ String not visualized on exam
o Ultrasound for IUD
– IUD in place, but with absent/malpositioned
▪ If IUD is difficult to visualize sonographically, look string
for shadowing – Malpositioned, but still in uterus
▪ Posterior shadowing best visualized when scanning – Perforated, outside of uterus
perpendicular to long axis of IUD – Expelled vaginally and no longer present
▪ Volume contrast imaging with 2-4 mm slice ▪ Prolonged pain/dyspareunia
thickness can aid in IUD detection – Malpositioned or perforated
▪ Low IUDs may spontaneously migrate into more ▪ Irregular menses/dysmenorrhea
appropriate position ▪ Infection
▪ 3D sonography helpful for diagnosis of o Other symptoms
embedment and displacement ▪ LNG-IUS is associated with steroidal side effects:
▪ 3D is helpful for laying out long axis of IUD when Mood changes, oily skin, acne
uterus is curved
o HSG for tubal occlusion device • Placement
o IUD
▪ Must have good cornual distention for satisfactory
▪ Placed at speculum exam without imaging
evaluation of tubal occlusion
guidance
▪ Avoid cervical dilation to maintain good seal and
– May use US guidance if difficulty due to
distention
submucosal fibroids or strong resistance
o HSG pitfalls for tubal occlusion device
– Entire IUD should be in endometrial cavity with
▪ Essure/Adiana: Venous or lymphatic intravasation
no portion in endocervical canal
– Result of tubal obstruction coupled with
– Retrieval string expected to extend 2-3 cm out of
excessive injection pressure
external os
– Contrast enters venous and lymphatic drainage
– Followup exam in 6 weeks to ensure string is
of uterus/tube mimicking tubal patency
visible
– Delayed supine radiography shows intravasated
▪ Safe in teenagers, nulliparous, immediately after
contrast flowing away from tube, whereas
delivery or abortion
peritoneal contrast pools around patent tube ▪ Status post uterine artery embolization
▪ Adiana
– Best to wait until uterine size has stabilized and
– Excessive pressure may dislodge matrix and open
no evidence of continued fibroid necrosis
occluded tubes – Usually 3-6 months
o Essure
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Uterus
▪ Hysteroscopically placed into fallopian tubes – Progestins thicken cervical mucus providing
– Device should span uterotubal junction better barrier to ascending infection
– Ideally 3-8 expanded outer coils are visible o Essure
in uterine cavity hysteroscopically at time of ▪ Avoid general anesthesia, incision, postop pain
insertion ▪ Fewer complications (bleeding, infection, injury to
– If more than 18 coils are visible trailing in adjacent organs)
uterine cavity, insert should be removed ▪ Lower healthcare costs
•Contraindications •IUD complications
o IUD o Displacement (25%)
▪ Severe uterine distortion ▪ Usually asymptomatic, ± cramping or bleeding
– Bicornuate uterus ▪ Decreased effectiveness
– Cervical stenosis ▪ Levonorgestrel-releasing IUDs continue to provide
– Fibroids distorting uterine cavity contraception despite displacement
▪ Active pelvic infection ▪ No guidelines for management
– PID, endometritis, mucopurulent cervicitis, o Uterine expulsion (10%)
pelvic tuberculosis ▪ Confirm expulsion with KUB
– Presence of foreign body may prevent resolution ▪ Asymptomatic or pain and spotting
of infection ▪ Not affected by uterine position
– May place IUD 3 months after treatment ▪ Increased risk with: Insertion early in menstrual
▪ Unknown or suspected pregnancy cycle, nulliparity, menorrhagia, immediate
▪ Unexplained abnormal uterine bleeding postpartum insertion, severe uterine distortion
▪ Wilson disease or copper allergy (copper IUD only) (submucosal fibroids, müllerian anomaly)
▪ Breast cancer or active liver disease (LNG-IUS only) o Embedment (18%)
o Essure ▪ IUD penetrates endometrium or myometrium
▪ Prior tubal ligation without extension through uterine serosa
▪ Can only have 1 insert placed (unilateral occluded ▪ More common with smaller fundal diameter
tube or unicornuate uterus) ▪ Treat empirically with antibiotics, otherwise
▪ Pregnancy termination or delivery within 6 weeks variable management
▪ Allergy to contrast material o Complete perforation (0.1%)
▪ Recent pelvic infection ▪ IUD penetrates through uterine serosa and is
▪ May elicit allergic reaction in patients with allergy partially or completely in peritoneal cavity
to nickel ▪ Periprocedural perforation suspected at time of
•Advantages insertion if there is acute pain and string is missing
o IUD ▪ Increased risk with lactation, < 6 months
▪ Highly effective and reversible postpartum, nulliparity, uterine abnormality,
▪ Safe in teenagers, nulliparous, immediately after inexperienced operator
delivery or abortion ▪ Related to ↓ estrogen levels and resultant uterine
▪ ↓ risk of endometrial and cervical cancer shrinkage
▪ Can avoid exogenous hormones (copper only) ▪ Prior cesarean delivery does not increase risk of
▪ Can avoid progestin-related side effects (copper perforation
only) ▪ Complications: Abdominal infection/abscess in
– Amenorrhea, unscheduled bleeding, spotting 16%; adhesions causing infertility, pain, bowel
with LNG-IUS obstruction; rarely perforate other structures
– No interruption in menstrual cycle with copper causing peritonitis, fistulas, hemorrhage
IUD ▪ Treat empirically with antibiotics and surgical
▪ ↓ dysmenorrhea and ↓ menstrual bleeding (LNG- removal to prevent formation of adhesions
IUS only) •Essure complications
▪ Provide contraception even if malpositioned (LNG- o Adverse events
IUS only) ▪ Pelvic pain, back pain, dysmenorrhea, dyspareunia
▪ Endometrial protection (LNG-IUS only) (2.5-9%)
– Possible protective effect in women on ▪ Headache (2.5%)
tamoxifen ▪ Vaginal discharge/infection (1.5%)
– Off-label use to prevent endometrial hyperplasia o Tubal patency (3% unilateral failure of occlusion)
in peri/postmenopausal women on estrogen ▪ Contrast fills tube past lateral end of outer coil
therapy ▪ Contrast spills into peritoneal cavity
▪ Endometriosis (LNG-IUS only) o Central migration with expulsion into uterine cavity
– May ↓ pain/dysmenorrhea and delay recurrence (0.6-3%)
after surgery ▪ ≥ 50% of inner coil trailing into uterine cavity
▪ ↓ risk of PID (LNG-IUS only) o Distal placement
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▪ Uterine end of inner coil > 30 mm past contrast- • Intraperitoneal position of LNG-IUS results in plasma
filled cornua LNG levels 10x higher than plasma level of LNG
▪ Partial/complete extrusion into peritoneal cavity observed with LNG-IUS placed in utero
▪ Tubal/uterine perforation occurs in 1-2% o High plasma LNG level suppresses ovulation
– Not associated with long-term adverse events o Misplaced LNG-IUS should be removed when
▪ Migration into peritoneal cavity occurs in 0.1% pregnancy is desired
– Consider surgical removal due to increased risk
of adhesions and small bowel obstruction
Demographics
• Epidemiology Image Interpretation Pearls
• Entire IUD should be visualized within endometrial
o IUDs are most common method of reversible
cavity with cross bars in appropriate orientation
contraception worldwide
▪ Used by 23%
o Less common in US SELECTED REFERENCES
▪ Used by 7.7%
1. Dean G et al: Intrauterine contraception (IUD): Overview:
Natural History & Prognosis UpToDate. http://www.uptodate.com/contents/
• IUD intrauterine-contraception-iud-overview. Updated July 14,
2014. Accessed August 15, 2014
o 98-99% effective, easily removable 2. Boortz HE et al: Migration of intrauterine devices: radiologic
o Most cost-effective reversible method of findings and implications for patient care. Radiographics.
contraception 32(2):335-52, 2012
o Synchronous pregnancy 3. Guelfguat M et al: Imaging of mechanical tubal occlusion
▪ 2/100 women per year of IUD use devices and potential complications. Radiographics.
▪ Most common in 1st year of use 32(6):1659-73, 2012
▪ Spontaneous abortion in 40-50% 4. Barber M et al: Uterine perforation and migration of
an intrauterine contraceptive device in a 24-year-old
▪ Associated adverse outcomes patient seeking care for abdominal pain. J Chiropr Med.
– Neonatal complications (low birth weight) 10(2):126-9, 2011
– Premature labor, premature rupture of 5. Moschos E et al: Does the type of intrauterine device
membranes affect conspicuity on 2D and 3D ultrasound? AJR Am J
– Septic complications of chorioamnionitis, fetal Roentgenol. 196(6):1439-43, 2011
infection, maternal septicemia 6. Benacerraf BR et al: Three-dimensional ultrasound detection
▪ Decrease risks with early removal, best done under of abnormally located intrauterine contraceptive devices
which are a source of pelvic pain and abnormal bleeding.
US guidance
o Ectopic pregnancy
7. Peri N et al: Imaging of intrauterine contraceptive devices. J
▪ Lower rates of intrauterine and ectopic pregnancy Ultrasound Med. 26(10):1389-401, 2007
in women using IUDs 8. Muhler M et al: [How safe is magnetic resonance imaging
▪ IUD + positive pregnancy test: Assumed to be in patients with contraceptive implants?] Radiologe.
ectopic until proven otherwise 46(7):574-8, 2006
o IUD insertion can be used as form of emergency 9. Valsky DV et al: The shadow of the intrauterine device. J
contraception Ultrasound Med. 25(5):613-6, 2006
• Essure
10. Letti Muller AL et al: Transvaginal ultrasonographic
assessment of the expulsion rate of intrauterine devices
o Success rates of 83-94.1% inserted in the immediate postpartum period: a pilot study.
o Increased risk of tubal ectopic pregnancy with tubal Contraception. 72(3):192-5, 2005
occlusion devices 11. Morales-Rosello J: Spontaneous upward movement of lowly
• Adiana placed T-shaped IUDs. Contraception. 72(6):430-1, 2005
o Tubal patency rates of 8.8% at 3 months and 4-5% at 12. Schiesser M et al: Lost intrauterine devices during
pregnancy: maternal and fetal outcome after ultrasound-
6 months
guided extraction. An analysis of 82 cases. Ultrasound
o Pregnancy rate 1.08% at 1 year, 1.82% at 3 years
Obstet Gynecol. 23(5):486-9, 2004
Treatment 13. Caliskan E et al: Analysis of risk factors associated with
• Pregnancy with IUD in place treated with sonographic- uterine perforation by intrauterine devices. Eur J Contracept
Reprod Health Care. 8(3):150-5, 2003
guided IUD removal
• Infection with IUD in place
14. Hubacher D et al: Noncontraceptive health benefits of
intrauterine devices: a systematic review. Obstet Gynecol
o Removal of IUD, drainage of abscess if needed, and Surv. 57(2):120-8, 2002
antibiotics 15. Stanford JB et al: Mechanisms of action of intrauterine
o If chlamydia/gonorrhea testing at time of IUD devices: update and estimation of postfertilization effects.
insertion comes back positive, can treat without IUD Am J Obstet Gynecol. 187(6):1699-708, 2002
16. Thonneau P et al: Risk factors for intrauterine device failure:
removal and retest
•
a review. Contraception. 64(1):33-7, 2001
Uterine perforation may be symptomatic or 17. Tatum HJ et al: Management and outcome of pregnancies
asymptomatic associated with the Copper T intrauterine contraceptive
o Perforated IUD should be removed laparoscopically device. Am J Obstet Gynecol. 126(7):869-79, 1976
o IUD in pelvis can perforate into any organ including
bowel, ovary, or bladder
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Uterus
ultrasound shows a linear
shadowing structure centered
in the uterine cavity. The stem
of levonorgestrel-secreting IUDs
are typically not echogenic and
best located by identifying the
shadowing between the
echogenic ends of the device.
(Right) 3D ultrasound image in
the same patient shows the stem
and arms of the IUD are
appropriately positioned. 3D
imaging is particularly helpful
in visualizing levonorgestrel-
secreting IUDs and excluding
complications.

shows a linear signal void
corresponding to the stem
of an IUD in the posterior
uterine myometrium. All IUDs
are signal voids on all MR
sequences. (Right) Longitudinal
transvaginal ultrasound shows a
normal uterus and endometrial
echo complex . No IUD
was seen in the uterus. Careful
observation noted a shadowing
linear echogenic structure
in the cul de sac consistent
with perforation and peritoneal
location of the IUD.
(Left) Anteroposterior radiograph

shows an IUD overlying
the right iliac crest. Location of
the IUD above the pelvic brim
and 90° or 180° rotation are
indicators of uterine perforation
and intraabdominal location.
malpositioned IUD located in
the lower uterine segment and
cervix, as well as embedment
of the arms . A previously
unknown pregnancy was found
with a gestational sac in the
uterine cavity.
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(Left) Sagittal NECT in a

patient with pelvic pain shows
a malpositioned IUD with
the arms penetrating
the anterior and posterior
uterine body. Penetration of
the myometrium by the IUD
without extension through
the serosa is embedment.
(Right) 3D ultrasound image
shows a rotated low-lying
IUD. Embedment of the right
arm into the myometrium
is demonstrated on the 3D
reconstruction, but was not
seen on the conventional
ultrasound images.

shows a retroflexed uterus
with curvilinear signal voids
at the uterotubal junction
bilaterally compatible with
the patient's Essure devices.
same patient shows the tubal
occlusion devices to better
advantage due to greater
associated susceptibility
artifact on this sequence.
(Left) Anteroposterior
hysterosalpingogram
(HSG) shows appropriately
positioned Essure devices
and tubal occlusion. (Right)
Transverse transabdominal
ultrasound shows echogenic
curvilinear Essure devices
at the uterotubal junction
bilaterally.
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Uterus
(Left) Anteroposterior scout
image from HSG shows bilateral
Essure tubal occlusion devices.
Note the radiopaque markers
at each end of the coils. The
tubal end markers are at a
fixed distance relative to each
other. However, the uterine
end markers may normally
be at variable distances from
each other depending on the
degree of expansion of the outer
coil. (Right) Anteroposterior
HSG image in the same patient
confirms tubal occlusion and
shows the expanded outer coil
.
(Left) Anteroposterior scout

image from HSG shows 2 Essure
devices , which are positioned
abnormally close to each other.
HSG with adequate uterine
distension is required in the
US to confirm device position
and tubal occlusion. (Right)
Anteroposterior HSG in the same
patient shows both devices
located in tandem on the left.
The abnormal configuration of
the endometrial cavity is due to
prior endometrial ablation, which
is a contraindication to Essure
placement due to the inability
to generate adequate distention
at HSG in order to check tubal
patency.

patient confirms location of
both devices on the left
(partially visualized on this
image). Intraluminal location of
the device cannot be confirmed
on CT because the fallopian tube
is normally beyond the resolution
of CT. (Right) Axial T1WI C+ FS
linear susceptibility artifact at
the left uterotubal junction due
to the Essure devices. No artifact
was seen on the right. As with
CT, intraluminal location cannot
be confirmed on MR.
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Uterus POST CESAREAN SECTION APPEARANCE
Key Facts
Terminology o ± fluid within triangular "defect" resulting from
• C-section scar, niche, pouch, diverticulum, isthmocele myometrial thinning
o Shadowing or foci of susceptibility artifact in LUS
• Acute changes: Puerperium or postpartum period from suture material
•
(delivery to 6-8 weeks)
• Chronic changes: Remote hysterotomy for cesarean Sonohysterography
o Focal thinning of myometrium in LUS fills with
section
saline
Imaging • Hysterotomy location depends on whether cesarean
• Acute changes section was emergent or elective
o Edema ± small hematoma at myometrial incision
o ± small amount of intrauterine gas Top Differential Diagnoses
o Small bladder flap hematoma (< 2 cm), often at • Myomectomy scar
lateral margins of hysterotomy • Marked uterine anteflexion
o Minimal free pelvic fluid • Myometrial cyst
• Chronic changes
Clinical Issues
o Focal thinning of anterior myometrium in lower
• Most are asymptomatic
• May have abnormal uterine bleeding
uterine segment (LUS) above internal os
(Left) Anteroposterior
hysterosalpingogram in a
patient with prior cesarean
delivery shows bilateral
diverticula arising from the
lower uterine segment. (Right)
ultrasound image in a patient
with remote cesarean delivery
shows focal thinning of the
myometrium of the anterior
lower uterine segment with
. Fluid fills the defect .

shows the fluid-filled cesarean
scar defect . The length
of scar is measured side-to-side
in the transverse plane. (Right)
demonstrates the cesarean
scar measurement technique
for the width and depth
of the scar, as well as the
residual myometrial thickness
.
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POST CESAREAN SECTION APPEARANCE
Uterus
TERMINOLOGY ▪ May see minimal outer contour abnormality of
anterior LUS in sagittal plane
Synonyms ▪ Foci of susceptibility artifact in LUS related to
• C-section scar, niche, pouch, diverticulum, isthmocele suture material
Definitions
• T2WI
o Acute changes
• Acute post cesarean section ▪ Small heterogeneous collection at incision or
o Changes normally seen in puerperium or postpartum bladder flap
period (delivery to 6-8 weeks) ▪ No myometrial defect
• Chronic post cesarean section o Chronic changes
o Changes normally seen after remote hysterotomy for ▪ Takes 3 months to develop
cesarean section ▪ Focal low signal thinning of myometrium in
anterior LUS above internal os
▪ Focal disruption of uterine zonal anatomy
IMAGING
▪ Triangular defect underlying scar filled with
General Features hyperintense endometrium or fluid
o Acute changes
▪ Minimal edema and gas at myometrial incision
o Acute changes
▪ Small bladder flap hematoma or myometrial
▪ Spectrum of appearances
hematoma
– Normal myometrium
▪ Minimal free pelvic fluid
– Focal hypoechoic edema
o Chronic changes
– Hypoechoic defect filled with small focal
▪ Focal thinning of anterior myometrium in lower
echogenic clot
uterine segment (LUS) above cervical internal os
▪ May see suture in incision as well-defined linear
▪ May or may not have fluid within triangular
echoes
"defect" resulting from myometrial thinning
▪ May have minimal free peritoneal fluid
• Location
▪ May have small bladder flap hematoma (< 2 cm)
o Hysterotomy location depends on whether cesarean
▪ Often have small abdominal wall collection
section was emergent or elective o Chronic changes
▪ During labor, LUS is stretched as cervix thins and ▪ Focal thinning of myometrium in anterior LUS
dilates, resulting in a low incision (close to cervix) above internal os
▪ In an elective procedure, incision is made 2-3 cm ▪ Shadowing emanating from LUS related to suture
below uterovesical peritoneal reflection with scar material
ending up halfway between uterovesical fold and ▪ Triangular defect may contain fluid
internal os ▪ Standardized scar measurements
• Size – Length: Side-to-side measurement in transverse
o Mean LUS residual myometrial thickness at scar is 1.9 plane
± 1.4 mm – Width: Craniocaudal measurement at
▪ Nulliparous control: 2.3 ± 1.1 mm endocavitary surface in sagittal plane
▪ Multiparous control: 3.4 ± 2.2 mm – Depth: Anteroposterior measurement from
o Mean depth of triangular "defect" is 6.17 ± 3.6 mm uterine cavity to scar apex in sagittal plane
▪ Range: 2.5-11.5 mm – Residual myometrial thickness: Scar apex to
CT Findings uterine serosa in sagittal plane
• Acute changes • Sonohysterography
o Hysterotomy best seen in sagittal plane o Focal thinning of myometrium in LUS fills with
▪ Edema along myometrial incision saline
▪ 1/2 may have full thickness defect in anterior LUS Hysterosalpingography (HSG)
myometrium
▪ Small bladder flap hematoma (< 2 cm)
• 60% of patients with history of cesarean delivery have
scar diverticula
o Small amount of intrauterine gas
o Minimal pelvic free fluid
• Focal outpouching (65%) > thin linear defect (35%)
• Chronic changes not well seen due to inadequate soft
• LUS (54%) > uterine isthmus (36%) > upper
endocervical canal (10%)
tissue contrast
• Unilateral (46%) = bilateral (46%) > midline (8%)
MR Findings Imaging Recommendations
• T1WI • Best imaging tool
o Acute changes
o TVS
▪ Hyperintense subacute hematoma in myometrium o Saline infusion sonohysterography
at incision
▪ Defect will fill with fluid subjacent to focal
▪ Hyperintense small (< 2 cm) bladder flap
myometrial scar/thinning
hematoma
o Chronic changes • Protocol advice
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Uterus POST CESAREAN SECTION APPEARANCE
o Best seen in longitudinal view of uterus or sagittal ▪ Rarely bladder, ureteral, bowel injury (≤ 1%)
plane o Respiratory morbidity in newborn infants
• Complications
o Acute/puerperium
▪ Endometritis (↑ rate compared with vaginal
Myomectomy Scar delivery)
• History and location of finding aid diagnosis ▪ Wound infection (5%)
• Usually less focal ▪ Ovarian vein thrombophlebitis
▪ Bladder flap, subfascial, rectus sheath hematomas
• Typically no associated triangular "defect" ▪ Pseudoaneurysm
Marked Uterine Anteflexion o Late/remote
• True long-axis images aid diagnosis ▪ Uterine rupture or dehiscence
• Search for true sagittal plane ▪ Abnormal placentation in future pregnancies
• Endocervical and endometrial canal should be visible – Accreta, increta, or percreta
▪ Cesarean scar pregnancy
on a single image
▪ Incisional endometriosis
• Assess myometrial thickness and integrity on sagittal – Subcutaneous, rectus muscle/sheath
scan
– Hysterotomy
Myometrial Cyst ▪ Intermenstrual bleeding
• No associated myometrial thinning • > 3 prior cesarean sections results in much greater risk
of uterine rupture during labor
PATHOLOGY • No correlation between number of cesarean deliveries
and mean size of scar or residual myometrial thickness
General Features Demographics
• Etiology • Age
o Post cesarean delivery with low transverse incision o Women of childbearing age and older
Gross Pathologic & Surgical Features • Epidemiology
• 3 types of cesarean section scars are described in o Rates of primary and repeat cesarean deliveries have
resected uteri increased since 1996
o Thick muscle layer with shallow groove ▪ 32.8% in USA in 2010
o Lack of muscle layer replaced by connective tissue ▪ Approaching 50% in China
o Lack of muscle layer
Treatment
Microscopic Features • Surgery for patients with intractable bleeding and with
• Scarring and retraction possible interference with embryo implantation from
• Growth of fibrous tissue blood in defect
• Suture material • Hysteroscopic guidance to resect fibrotic tissue that
• Occasional congested endometrium above scar recess overhangs scar to reduce blood pooling and improve
menstrual drainage
CLINICAL ISSUES DIAGNOSTIC CHECKLIST

Presentation Image Interpretation Pearls
• Most common signs/symptoms • Myometrial thinning in anterior LUS above internal os
o Most are asymptomatic
o May have abnormal uterine bleeding • Shadowing or susceptibility artifact in LUS from suture
material
▪ Intermenstrual spotting due to accumulation of
blood in defect or poor myometrial contractility
• Advantages of cesarean delivery include lower SELECTED REFERENCES
frequency of the following conditions 1. Hiller N et al: CT appearance of the pelvis after Cesarean
o Postpartum hemorrhage delivery--what is considered normal? Clin Imaging.
o Perineal laceration 37(3):514-9, 2013
o Urinary incontinence 2. Plunk M et al: Imaging of postpartum complications:
o Obstetrical trauma a multimodality review. AJR Am J Roentgenol.
o Neonatal intracranial hemorrhage 200(2):W143-54, 2013
o Neonatal asphyxia/encephalopathy 3. Naji O et al: Standardized approach for imaging and
o Brachial plexus birth injury measuring Cesarean section scars using ultrasonography.
o Neonatal infections
•
4. Rodgers SK et al: Imaging after cesarean delivery: acute and
Disadvantages of cesarean delivery chronic complications. Radiographics. 32(6):1693-712,
o Possible general anesthesia 2012
o Greater length of hospital stay 5. Woo GM et al: The pelvis after cesarean section and vaginal
o ~ 12% rate of intraoperative complications (emergent delivery: normal MR findings. AJR Am J Roentgenol.
161(6):1249-52, 1993
cesarean delivery)
2 ▪ Usually blood loss or uterine/cervical injury
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POST CESAREAN SECTION APPEARANCE
Uterus
(Left) Sagittal CECT in a patient
3 days post cesarean delivery
shows gas in the uterine
cavity and a defect in the
lower uterine segment. Small
amounts of gas and even a full
thickness myometrial defect may
normally be seen immediately
post partum. (Right) Sagittal
shows minimal hyperdense
fluid in the bladder flap, the
extraperitoneal space between
the lower uterine segment and
urinary bladder. Hematomas up
to 2 cm in size are considered
normal and commonly occur
at the lateral margins of the
hysterotomy.

prior cesarean delivery and
daily spotting for 6 weeks
shows focal myometrial thinning
in the anterior lower uterine
segment. There is minimal
anechoic fluid in the scar defect
. (Right) Sagittal T2WI FSE
focal myometrial thinning and
loss of zonal anatomy in the
anterior lower uterine segment.
Hyperintense signal fills the
myometrial defect , which
can be endometrium or complex
fluid. Diffuse adenomyosis is
incidentally noted.
(Left) Axial T2WI FS MR in the

same patient shows hyperintense
blood filling the cesarean scar
defect. Patients with history of
cesarean delivery have a higher
incidence of intermenstrual
spotting, thought to be due to
accumulation of blood in the
defect. (Right) Sagittal T1WI FS
MR best shows susceptibility
artifact related to sutures.
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Uterus ADENOMYOSIS
Key Facts
Terminology • Definite advantage to MR when associated
• Presence of heterotopic endometrial glands and stroma abnormalities present (leiomyoma, endometriosis)
• MR best performed in late proliferative-early secretory
in myometrium with smooth muscle hypertrophy
phase of cycle
Imaging
• Enlarged globular uterus without well-defined mass Top Differential Diagnoses
• Leiomyoma
• Smooth external uterine contour • Menstrual and early proliferative phase of cycle
• Asymmetric uterine wall thickening, posterior > • Cystic glandular hypertrophy
anterior
• Ill-defined endometrial-myometrial interface • Diffuse myometrial hypertrophy
• Subendometrial cysts • Low-grade endometrial stromal sarcoma
• Endometrial pseudowidening • Metastasis to uterine corpus
• Linear striations (finger-like projections) radiating out Pathology
from endometrium into myometrium
• US: "Rain shower," subendometrial echogenic nodules • 90% of cases occur in multiparous women
or linear striations • Associated with leiomyomas, endometriosis, or
• MR: Ill-defined thickened junctional zone ≥ 12 mm endometrial polyps
• Increased risk of endometrial carcinoma
with ↑ signal intensity T1 and T2 foci

ultrasound shows an enlarged
uterus with asymmetric
thickening of the posterior
wall. The endometrial-
myometrial junction is ill
defined with echogenic
striations emanating from
the endometrium . (Right)
Coronal oblique T2WI FSE MR
in the same patient confirms
asymmetric thickening of the
posterior wall of the uterus.
There is diffuse thickening
of the junctional zone ,
particularly posterior with
punctate high signal foci .
(Left) Hysterosalpingography
shows marked irregularity of
the uterine cavity contour
with multiple diverticula
extending out from
the endometrium. This is
compatible with the superficial
form of adenomyosis, which
communicates with the
endometrial cavity. The
diverticula represent the
subendometrial cystic spaces
seen on other modalities.
shows a retroflexed uterus
with diffuse thickening of the
junctional zone , consistent
with diffuse adenomyosis.
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ADENOMYOSIS
Uterus
o Susceptibility-weighted imaging may help
TERMINOLOGY
demonstrate small hemorrhagic foci
Synonyms ▪ Punctate signal voids due to hemosiderin deposits
• Endometriosis interna indicate old hemorrhagic foci
Definitions
• T2WI
o Diffuse and symmetric thickening of JZ
• Presence of heterotopic endometrial glands and ▪ JZ ≥ 12 mm highly predictive of adenomyosis
stroma in myometrium with adjacent smooth muscle ▪ JZ ≤ 8 mm essentially excludes adenomyosis
hypertrophy ▪ JZ 8-12 mm indeterminate, consider ancillary
criteria
IMAGING o JZ thickness to total myometrial thickness ratio >
40-50%
General Features o Ancillary criteria
• Best diagnostic clue ▪ Margins of JZ ill defined
o Enlarged globular uterus without well-defined mass ▪ High SI foci (2-6 mm) present within thickened JZ
or external contour abnormality in 50%
o Asymmetric uterine wall thickening – Represent heterotopic endometrial glands
▪ Posterior > anterior – Occasional fluctuation in appearance and
o Ill-defined endometrial-myometrial interface number of high SI foci during menstrual phase
o Myometrial cysts ▪ Pseudowidening of endometrium
▪ 2-6 mm, often subendometrial – High SI linear striations (finger-like projections)
▪ Seen in 50% radiating out from endometrium into
▪ Swiss cheese appearance of myometrium myometrium
▪ Differentiate from vessels, which are normally – Can fluctuate according to hormonal state
found in outer 1/3 of myometrium o Accuracy of MR: 85-90%
o Relative absence of mass effect o Sensitivity of MR: 78-88%
• Morphology o Specificity of MR: 67-93%
o Definite advantage to MR when associated
o Diffuse adenomyosis
▪ Diffuse abnormality and thickening of junctional abnormalities present (leiomyoma, endometriosis)
zone (JZ) o MR limited when JZ is not well visualized
o Segmental adenomyosis ▪ 20% of premenopausal women
▪ Focal abnormality contiguous with JZ ▪ 30% of postmenopausal women
o Superficial form • T1WI C+
▪ Thickening of JZ not extending deeper than 1/3 of o No increase in diagnostic accuracy
myometrial thickness o Early-phase perfusion abnormalities
▪ Subendometrial cystic spaces communicate with o "Swiss cheese" appearance due to lack of
endometrial cavity enhancement of dilated cystic glands
o Deep form • Physiologic or pathologic states may affect MR
▪ Endometrial invasion penetrates deeper than 1/3 appearance
of myometrial thickness o Secretory transformation including decidualization
▪ Loss of continuity with endometrial cavity of adenomyotic endometrium
▪ May occur during pregnancy, exogenous
Radiographic Findings
• Hysterosalpingography
progesterone administration, or without hormonal
stimulation
o 1-4 mm diverticula extending out from endometrial ▪ Increase size of T2-bright foci in area of
cavity adenomyosis
o Rigid or dilated uterine horn ▪ Absence of T1-bright foci
o Tuba erecta: Vertical rigid proximal tubal segment ▪ Adenomyotic lesion better defined
• Sonohysterography ▪ Hemorrhage within adenomyosis post childbirth
o Subendometrial cystic spaces communicate with possibly due to rapid decreased blood volume to
endometrial cavity uterus with relative ischemia
o Congestion or edematous change
CT Findings
▪ Diffuse or focal ↑ T2
• CECT o Hormonal therapy with GnRH or menopause
o Not a useful diagnostic tool; findings nonspecific
▪ Decrease in JZ width
o May see early arterial enhancement of thickened JZ
▪ Decrease or resolution of high T2 foci
during menstrual phase, with punctate hypodense o Changes fluctuate, follow-up MR may help confirm
foci
o Often not detectable on CT due to homogeneous Ultrasonographic Findings
enhancement of uterus • Grayscale ultrasound
o Enlarged globular uterus
MR Findings o Heterogeneous myometrial echotexture without
• T1WI FS focal mass
o High signal intensity (SI) foci representing
▪ Echogenic areas represent heterotopic
hemorrhage of heterotopic endometrial tissue (20%)
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Uterus ADENOMYOSIS
▪ Hypoechoic areas represent hypertrophied smooth • Best avoided if MR scheduled during secretory phase
muscle
o Poor definition of endo-myometrial junction Cystic Glandular Hypertrophy
▪ Corresponds to JZ thickening on MR • Cystic change is in endometrium, not
o Subendometrial echogenic nodules or linear subendometrium and junctional zone
striations • MR or SIS may help differentiate
▪ Correspond to invasion of endometrial glands into Diffuse Myometrial Hypertrophy
inner layer of myometrium
▪ Endometrial pseudowidening • Diffuse, mild uterine enlargement
o Myometrial cysts in 50% • Proportional and symmetric widening of JZ
o Borders remain well defined
▪ Anechoic, 2-6 mm, often subendometrial
o Absence of hyperintense foci
▪ May be hemorrhagic and echogenic
▪ Correspond to dilated endometrial glands Low-Grade Endometrial Stromal Sarcoma
▪ Highly specific for diagnosis
o Hypoechoic linear striations emanating from
• Rare malignant mesenchymal tumor in young women
myometrium ("rain shower" appearance)
• Highly infiltrative tumor invades myometrium with
preservation of muscle bundles within tumor
▪ Edge shadows from whorls of smooth muscle o Preserved muscle fibers seen as T2 hypointense
hypertrophy worm-like structures in high signal tumor
o Accuracy of transvaginal ultrasound (TVUS): 68-86%
o Sensitivity of TVUS: 53-89% • Tumor extension along vessels
o Specificity of TVUS: 67-98% Metastasis to Uterine Corpus
• Color Doppler • Diffuse hypointense area in myometrium with uterine
o Speckled pattern of increased vascularity, without enlargement
large peripheral vessels • Rare, most common primaries are breast carcinoma
(invasive lobular), gastric cancer and lymphoma
o TVUS as initial imaging modality PATHOLOGY
o MR as problem solving modality
General Features
▪ Reserved for indeterminate cases or for treatment
planning (uterus-sparing options) • Etiology
o Stratum basalis layer of endometrium invades
▪ Best modality if adenomyosis is accompanied by
myometrium causing surrounding smooth muscle
leiomyomas and endometriosis
• Protocol advice
hyperplasia
▪ Heterotopic glands invade myometrium for depth
o MR
of at least 2.5 mm past basal layer of endometrium
▪ Multiplanar T2 FSE is most useful sequence
▪ Smooth muscle hypertrophy forms bulk of lesion
▪ Best performed in late proliferative-early secretory o Unknown etiology, likely multifactorial with
phase of menstrual cycle
hereditary component
– Increased T2 signal of myometrium in secretory
▪ Postulated endometrial migration via basement
phase improves visualization of low-signal JZ
membrane defect or lymphatic/vascular channels
– Decreased T2 signal of myometrium in o Tamoxifen known to increase incidence in
menstrual-early proliferative phase may cause
postmenopausal women
widening of JZ mimicking adenomyosis o Increased risk with uterine trauma from childbirth or
▪ High-resolution 3T imaging may improve
abortion, chronic endometritis
diagnostic accuracy
o Frequent association with leiomyomas,
DIFFERENTIAL DIAGNOSIS endometriosis, or endometrial polyps
o Increased risk of endometrial carcinoma
Leiomyoma
• Uterus enlarged by multiple circumscribed masses Gross Pathologic & Surgical Features
• Lobular external uterine contour • Firm, large, and globular uterus
• Hypoechoic, whorled appearance with edge shadowing • Cut surface of thickened myometrium is trabeculated,
• Homogeneous, well-defined, hypointense mass on may contain hemorrhagic foci
T2WI • Hypertrophy of myometrial smooth muscle
• May have calcification surrounding foci of heterotopic endometrial tissue
o Hypertrophy represented by low SI on T2WI,
• No relationship to JZ heterogeneity and decreased echogenicity on TVUS
Menstrual and Early Proliferative Phase of Cycle • Direct invasion of endometrial zona basalis into
• Pseudothickening of junctional zone on MR underlying myometrium
• Correlate with patient history
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ADENOMYOSIS
Uterus
o Presents as high SI or hyperechoic, finger-like
projections extending out from endometrium into
myometrium Consider
• Ectopic endometrium, cystically dilated endometrial • Differentiation from leiomyoma is critical due to
glands, &/or hemorrhage divergent management (uterine conservation for
o Ectopic endometrium: High SI foci on T2WI, leiomyoma vs. hysterectomy for adenomyosis)
echogenic nodules on TVUS
o Cystically dilated endometrial glands: High SI foci on Image Interpretation Pearls
T2WI, anechoic areas on TVUS • Enlarged globular uterus without well-defined mass
• Ill-defined endometrial-myometrial interface
• Subendometrial cysts
• Ectopic endometrium forms small or large islands in • US: "Rain shower," subendometrial echogenic nodules
myometrium surrounded by myometrial hypertrophy
• Ectopic endometrial glands are basalis type
or linear striations
o Do not respond to cyclic ovarian hormones • MR: Ill-defined thickened JZ ≥ 12 mm with high-signal
T1 and T2 foci
o Rarely may respond with secretory change, cyclic
hemorrhage, decidualization
• Rare feature: Adenomyosis with sparse glands SELECTED REFERENCES
o Pathologically mimicking low-grade endometrial 1. Levy G et al: An update on adenomyosis. Diagn Interv
stromal sarcoma Imaging. 94(1):3-25, 2013
2. Shitano F et al: Decidualized adenomyosis during pregnancy
and post delivery: three cases of magnetic resonance
CLINICAL ISSUES imaging findings. Abdom Imaging. 38(4):851-7, 2013
3. Kishi Y et al: Four subtypes of adenomyosis assessed by
Presentation magnetic resonance imaging and their specification. Am J
• Most common signs/symptoms Obstet Gynecol. 207(2):114, 2012
o Dysmenorrhea (30%), menorrhagia (50%), 4. Stamatopoulos CP et al: Value of magnetic resonance
metrorrhagia (20%) imaging in diagnosis of adenomyosis and myomas of the
o Superficial form usually asymptomatic uterus. J Minim Invasive Gynecol. 19(5):620-6, 2012
5. Novellas S et al: MRI characteristics of the uterine junctional
zone: from normal to the diagnosis of adenomyosis. AJR Am
o Pelvic pain, infertility J Roentgenol. 196(5):1206-13, 2011
• Clinical profile 6. Takeuchi M et al: Adenomyosis: usual and unusual imaging
o 90% cases in multiparous women manifestations, pitfalls, and problem-solving MR imaging
techniques. Radiographics. 31(1):99-115, 2011
Demographics 7. Champaneria R et al: Ultrasound scan and magnetic
• Age resonance imaging for the diagnosis of adenomyosis:
o 5th and 6th decade systematic review comparing test accuracy. Acta Obstet
• Epidemiology 8.
Gynecol Scand. 89(11):1374-84, 2010
Woodfield CA et al: CT features of adenomyosis. Eur J
o Prevalence of 5-70% in hysterectomy specimens Radiol. 72(3):464-9, 2009
▪ Due to variable criteria among pathologists 9. Dueholm M et al: Transvaginal ultrasound or MRI for
diagnosis of adenomyosis. Curr Opin Obstet Gynecol.
• Rare malignant degeneration to adenocarcinoma
19(6):505-12, 2007
10. Bergeron C et al: Pathology and physiopathology of
adenomyosis. Best Pract Res Clin Obstet Gynaecol.
Treatment 20(4):511-21, 2006
• Depends on age, symptoms, and desire for fertility 11. Chopra S et al: Adenomyosis:common and uncommon
• Hysterectomy is definitive treatment manifestations on sonography and magnetic resonance
• Symptomatic relief with NSAIDs 12.
imaging. J Ultrasound Med. 25(5):617-27; quiz 629, 2006
Kuligowska E et al: Pelvic pain: overlooked and
o If perimenopausal with anticipated cessation of
underdiagnosed gynecologic conditions. Radiographics.
ovarian function 25(1):3-20, 2005
• Hormonal therapy 13. Tamai K et al: MR imaging findings of adenomyosis:
o May not be as effective as in endometriosis due to correlation with histopathologic features and diagnostic
non-hormone-responsive basalis-type endometrium pitfalls. Radiographics. 25(1):21-40, 2005
o Menstrual suppression with danazol 14. Reinhold C et al: Uterine adenomyosis: endovaginal US
o Induce hypoestrogenic state with gonadotropin- and MR imaging features with histopathologic correlation.
Radiographics. 19 Spec No:S147-60, 1999
releasing hormone agonist 15. Ferenczy A: Pathophysiology of adenomyosis. Hum Reprod
▪ Favorable response in asymmetric adenomyosis Update. 4(4):312-22, 1998
with high SI foci on MR
• Uterine-sparing therapies with variable results
o Superficial adenomyosis: Endometrial ablation
o Deep adenomyosis: Myometrial excision, uterine
artery embolization
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Uterus ADENOMYOSIS

ultrasound shows an enlarged,
globular uterus without
a focal mass. The normal
smooth external contour of the
uterus is maintained. (Right)
Transverse color Doppler
random speckled pattern of
flow in the anterior wall of the
uterus, typical of adenomyosis.
This is in contrast to the
peripheral vascularity seen
with leiomyomas.

FSE MR shows asymmetric
thickening of the uterine
wall and junctional zone.
Hyperintense foci in the
junctional zone correspond to
cystic dilation of heterotopic
endometrial glands and give
a "Swiss cheese" appearance
to the myometrium. Finger-
like projections of
endometrium extend into the
myometrium. Adenomyosis
often coexists with uterine
leiomyomas . (Right) T1WI
shows hyperintense foci of
hemorrhage within the
junctional zone.

ultrasound of the uterus
shows multiple subcentimeter
anechoic subendometrial
cysts corresponding to
dilated cystic glands in the
heterotopic endometrial
tissue of adenomyosis. (Right)
shows multiple echogenic
foci throughout the
myometrium corresponding to
the heterotopic endometrial
glands in adenomyosis.
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ADENOMYOSIS
Uterus
shows pseudowidening of the
endometrium due to high-signal
linear striations extending out
from the endometrium into the
myometrium, consistent with
adenomyosis. (Right) Coronal
oblique T2WI FSE MR in the
same patient shows the linear
extension of endometrial
tissue into the myometrium to
better advantage. The superficial
heterotopic endometrial tissue
maintains contiguity with the
endometrial stripe.

globular uterus with normal
external contour and ill-defined
interface. Although there is no
focal mass, there is hypoechoic
shadowing and attenuation of
the ultrasound beam. (Right)
same patient with adenomyosis
shows diffuse homogeneous
thickening of the low signal
junctional zone . C-section
scar is noted.
(Left) Parasagittal T2WI FSE

a hypointense stellate lesion
in the rectouterine pouch
tethering the surrounding
structures. This is consistent
with the fibrous lesion of deep
pelvic endometriosis, a condition
commonly seen in conjunction
with adenomyosis. Also note
the markedly hypointense mass
posterior to the uterus.
homogeneous hyperintensity
of the mass posterior to
the uterus compatible with an
endometrioma, also often seen
with adenomyosis.
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Uterus ADENOMYOMA
Key Facts
• Solid, mass-like, localized form of adenomyosis • Leiomyoma
Imaging • Segmental adenomyosis
• Circumscribed, myometrial mass with ill-defined • Myometrial contraction
margins and mass effect • Subserosal endometriosis
• Most commonly corpus uteri, usually in myometrium • Endometrial polyp
• Ranges from 1-16 cm Pathology
• Solitary > multiple • Associated adenomyosis in 30%, leiomyomas in 50%
• Elliptical or round configuration • Infiltrating into surrounding normal tissues, in
• Solid ± cystic spaces
• Lesion frequently discontinuous with endometrial
contradistinction to leiomyoma, which displaces
normal tissues
complex
• T1: Isointense to myometrium, ↑ SI foci due to Clinical Issues
hemorrhage • 5th and 6th decades, 90% in multiparous women
• T2: Hypointense to myometrium, ↑ SI foci • Abnormal vaginal bleeding most common
• US: Hypoechoic, heterogeneous ill-defined mass • Dysmenorrhea, pain, mass, infertility, anemia
• Speckled pattern of increased vascularity

ultrasound shows an
anteflexed uterus with a
sessile subserosal hypoechoic
mass with ill-defined
margins arising from the
posterior uterine body. (Right)
in the same patient shows that
the mass is predominantly
hypoechoic and contains
punctate hyperechoic foci
. The mass is subserosal
projecting posterior to the
cervix .

shows the subserosal location
of the mass to better
advantage. This plane best
shows the mass effect on the
uterus and that the mass is not
contiguous with the junctional
zone as typically seen with
adenomyoma. Note incidental
hypointense endometrioma
in the left ovary. (Right)
Axial T1WI FS MR shows
scattered hyperintense
foci in the mass ,
compatible with hemorrhagic
endometrial glands. Note
that the endometrioma is
hyperintense as expected.
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Uterus
o Lesions abutting endometrial complex present as
TERMINOLOGY
focal widening of junctional zone (JZ), ≥ 12 mm
Definitions ▪ Angle between adenomyoma and JZ is frequently
• Solid, mass-like, localized form of adenomyosis acute
• Distinct from segmental adenomyosis ▪ High SI linear striations extending out from
endometrium into myometrium, seen less
commonly with adenomyoma than adenomyosis
IMAGING • T1WI C+
o Variable, not helpful for diagnosis
General Features o Early-phase hypoperfusion abnormalities with
• Best diagnostic clue dynamic T1 C+
o Circumscribed, myometrial mass with ill-defined
o "Swiss cheese" appearance due to lack of
margins and mass effect
• Location
enhancement of dilated cystic glands
o Delayed-phase enhancement of heterotopic
o Most commonly corpus uteri
endometrial foci (iso- or slightly hyperintense to
▪ Usually within myometrium adjacent myometrium)
▪ Occasionally involves/originates from
endometrium with polypoid growth, Ultrasonographic Findings
pedunculated or sessile • Grayscale ultrasound
▪ Rarely subserosal pedunculated mass o Hypoechoic, heterogeneous myometrial mass with
o Rarely cervix uteri ill-defined borders is typical
▪ Usually polypoid o Internal echogenic nodules or linear striations, more
▪ Endocervical type > endometrioid type common with adenomyosis than adenomyoma
• Size o Myometrial cysts in 50%
o Ranges from 1-16 cm ▪ 2-6 mm
▪ Largest are intramural ▪ Representing hemorrhagic foci ± endometrial cysts
o Solitary > multiple in heterotopic endometrial tissue
• Morphology • Color Doppler
o Appearance related to distribution and amount of o "Penetrating" vascular pattern within mass
heterotopic endometrial tissue relative to muscular ▪ Speckled pattern of increased vascularity
hypertrophy
o Elliptical or round configuration Imaging Recommendations
o Solid ± cystic spaces • Best imaging tool
o Lesion frequently discontinuous with endometrial o Transvaginal ultrasound (TVUS): Initial imaging
complex modality
o Poor definition of endo-myometrial junction in ▪ Color Doppler optimization for slow flow
lesions abutting endometrial complex facilitates differentiation from leiomyoma
o Typically less mass effect on endometrium or serosa o MR: Problem-solving modality
than leiomyomas, but greater than adenomyosis ▪ Reserved for indeterminate cases at TVUS
▪ Patients undergoing uterus-sparing surgery
Radiographic Findings • Protocol advice
• Hysterosalpingography (HSG) o Multiplanar T2 FSE is most useful sequence
o Has no role in diagnosing adenomyoma o High-resolution 3T imaging may improve diagnostic
accuracy
CT Findings o MR more sensitive than TVUS for differentiating
• CECT adenomyoma and leiomyoma
o Variable nonspecific appearance
o "Swiss cheese" appearance due to lack of
enhancement of dilated cystic glands DIFFERENTIAL DIAGNOSIS
MR Findings Leiomyoma
• T1WI FS • Well-defined mass ± calcification
o Isointense to myometrium • Hypoechoic whorled appearance and edge shadowing
o Occasional high signal intensity (SI) foci due to small on TVUS
areas of hemorrhage • Vessels at periphery of lesion on US (draping pattern)
o Susceptibility-weighted imaging may help • Hypointense to myometrium on T2WI, usually darker
demonstrate small hemorrhagic foci than adenomyoma if not degenerated
▪ Punctate signal voids due to hemosiderin deposits • May be indistinguishable from adenomyoma
indicate old hemorrhagic foci
• T2WI Segmental Adenomyosis
o Circumscribed, ill-defined, low SI myometrial mass • Poorly circumscribed, ill-defined borders, no mass
o High SI foci within mass in 50% effect
▪ Representing dilated heterotopic endometrial • Usually focally contiguous with JZ
glands • Typically forms obtuse angles with JZ
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Myometrial Contraction o Atypical hyperplastic glands with foci of squamous

• Transient, ill-defined, elliptical or triangular mass metaplasia
o Can be misdiagnosed as endometrial cancer invading
involving inner myometrium
• ± distortion of endometrial cavity myometrium
• Does not persist on all sequences
• Can use cine MR CLINICAL ISSUES
Subserosal Endometriosis Presentation
• Lesion originates from serosal surface of uterus and • Most common signs/symptoms
secondarily involves outer myometrium o Abnormal vaginal bleeding
• Associated findings of endometriosis: Solid plaque • Other signs/symptoms
between uterus and rectum, endometriomas, ovaries o Dysmenorrhea, pelvic pain, pelvic mass, infertility,
tethered to uterine surface, adhesions and anemia
• Morphology indistinguishable from adenomyoma o Prolapsing mass may be visible at external os
o Bright foci on T2- and T1-weighted images common
Endometrial Polyp o 90% cases in multiparous women
• Polypoid adenomyoma can appear identical to Demographics
endometrial polyp
• 2% of endometrial polyps are adenomyomas • Age
o 5th and 6th decades
Adenomyomatous Polyp Treatment
• Associated with tamoxifen therapy • Hysterectomy definitive treatment
• Endometrial polyp with significant amounts of smooth • Polypectomy and myomectomy successful without
muscle recurrence
• Histologically identical to polypoid adenomyoma
PATHOLOGY
Consider
General Features • Differentiation from leiomyoma critical due to
• Etiology divergent management (uterine conservation for
o Histogenesis poorly understood leiomyoma vs. hysterectomy for adenomyoma)
o Postulated endometrial migration via basement
membrane defect or lymphatic/vascular channels Image Interpretation Pearls
• Associated abnormalities • Circumscribed myometrial mass, ill-defined borders
o Diffuse adenomyosis seen in 30% • Dark on T2 with punctate ↑ T2 foci
o Leiomyomas seen in 50% • Penetrating vascular pattern for leiomyoma vs. draping
• Infiltrating into surrounding normal tissues, in pattern for adenomyoma on TVS
contradistinction to leiomyoma, which displaces
normal tissues SELECTED REFERENCES
• Infrequent menstrual-type changes in heterotopic
1. Levy G et al: An update on adenomyosis. Diagn Interv
endometrium
• Nodular aggregate of benign endometrial glands
2.
Imaging. 94(1):3-25, 2013
Takeuchi M et al: Adenomyosis: usual and unusual imaging
surrounded by endometrial stroma, which is bordered manifestations, pitfalls, and problem-solving MR imaging
by smooth muscle techniques. Radiographics. 31(1):99-115, 2011
o Lesion border merges to some degree with adjacent 3. Kitajima K et al: Magnetic resonance imaging of typical
myometrium polypoid adenomyoma of the uterus in 8 patients:
o Adjacent smooth muscle hypertrophy correlation with pathological findings. J Comput Assist
Tomogr. 31(3):463-8, 2007
Gross Pathologic & Surgical Features 4. Chopra S et al: Adenomyosis:common and uncommon
• Gross impression is frequently leiomyoma or manifestations on sonography and magnetic resonance
imaging. J Ultrasound Med. 25(5):617-27; quiz 629, 2006
endometrial polyp
• Firm consistency, gray-white surface on cut section 5. Tahlan A et al: Uterine adenomyoma: a clinicopathologic
• Cystic spaces filled with dark brown material (30%) review of 26 cases and a review of the literature. Int J
Gynecol Pathol. 25(4):361-5, 2006
Microscopic Features 6. Kuligowska E et al: Pelvic pain: overlooked and
• Nodular aggregate of benign endometrial glands underdiagnosed gynecologic conditions. Radiographics.

25(1):3-20, 2005
surrounded by endometrial stroma and smooth muscle 7. Tamai K et al: MR imaging findings of adenomyosis:
• Margin indistinct from surrounding normal correlation with histopathologic features and diagnostic
myometrium pitfalls. Radiographics. 25(1):21-40, 2005
• Must distinguish from adenofibroma and 8. Reinhold C et al: Uterine adenomyosis: endovaginal US
and MR imaging features with histopathologic correlation.
adenosarcoma
• Atypical polypoid adenomyoma 9.
Radiographics. 19 Spec No:S147-60, 1999
Ferenczy A: Pathophysiology of adenomyosis. Hum Reprod
o Rare variant
2 Update. 4(4):312-22, 1998
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ADENOMYOMA
Uterus
shows heterogeneous
myometrium without a
well-defined mass. There is
mass effect on the endometrial
stripe . Left adnexal mass
is incidentally noted. (Right)
shows a focal speckled pattern
in the area of myometrial
heterogeneity .

an ill-defined hypointense
myometrial mass with
punctate hyperintense foci in
the posterior uterine body. There
is mass effect on the endometrial
stripe. The junctional zone
is thin and symmetric. This
ill-defined mass with smooth
muscle hypertrophy and dilated
endometrial glands is consistent
with an adenomyoma. Left
adnexal mass is incidental.
further confirms the features of
a typical adenomyoma, showing
hyperintense foci compatible
with hemorrhagic endometrial
glands.
(Left) Coronal oblique T2WI FSE

MR shows focal thickening of the
junctional zone with multiple
foci of hyperintensity . In
contrast to an adenomyoma,
in which the mass is typically
discontinuous with the junctional
zone, this case shows focal
thickening of the junctional
zone consistent with segmental
adenomyosis. (Right) Axial
T1WI FS MR shows multiple
hyperintense foci in the
area of segmental adenomyosis
compatible with hemorrhagic
ectopic endometrial glands.
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Uterus CYSTIC ADENOMYOSIS
Key Facts
• Extensive hemorrhage within ectopic endometrial • Leiomyoma with hemorrhagic degeneration
glands of focal or diffuse adenomyosis • Leiomyoma with fatty degeneration
Imaging • Müllerian duct anomaly
• Circumscribed, complex cystic mass • Miscellaneous uterine cysts
• Usually intramural, typically in outer myometrium Pathology
• Variable size, 2-22 cm • Thick-walled cavities with brown staining of wall and
• Primarily round, ovoid, or lobulated surrounding myometrium, representing hemosiderin
• Thick wall with 2 zones (inner and outer) and hemolyzed blood
• Less commonly multicystic • Hemosiderin-laden macrophages around cyst wall
• Central cystic component with blood products in corresponding to low signal intensity on T2WI
different stages of organization • Endometrial glands line cyst wall
• T1: Homogeneously ↑ signal intensity, isointense wall • Cyst wall composed of myometrial tissue
• T2: Variable central cystic portion, thick ↓ signal Clinical Issues
• Pelvic pain ± palpable mass
intensity wall due to hemosiderin
• T1 C+: Rim enhancement
• More common in premenopausal, multiparous women

ultrasound shows a complex
intramural myometrial lesion
in the left uterine fundus.
Despite complex internal
echoes, posterior acoustic
enhancement suggests
its cystic nature. Simple
nabothian cyst is noted.
(Right) Axial CECT in the
cystic intramural mass with a
smooth, thick enhancing wall
.

the same patient shows mild
central hyperintensity with a
thick hypointense wall . The
lesion is located in the outer
myometrium, separate from
the high-signal endometrium
and low-signal junctional
zone . (Right) Axial T1WI
FS MR of the same lesion
shows marked homogeneous
central hyperintensity .
The thick wall is isointense to
myometrium on this sequence.
This hemorrhagic cystic
myometrial lesion with a thick
wall is consistent with cystic
adenomyosis.
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CYSTIC ADENOMYOSIS
Uterus
o Thick wall
TERMINOLOGY
▪ Low signal intensity due to hemosiderin
Definitions deposition
• Extensive hemorrhage within ectopic endometrial ▪ May develop 2 zones, "miniature uterus"
glands of focal or diffuse adenomyosis – Inner low signal similar to junctional zone
– Outer brighter myometrium
IMAGING • T1WI C+
o Central portion nonenhancing
General Features o Rim-enhancement relative to normal myometrium
• Best diagnostic clue ▪ Slightly hypointense on early CE images
▪ Isointense on delayed scans
o Circumscribed, thick-walled, complex cystic mass of
myometrial origin Ultrasonographic Findings
o Separate endometrial cavity with a normal
configuration (both cornua present)
o Thick-walled, cystic, myometrial mass
• Location o Central cystic portion
o Most frequently intramural ▪ Variable appearance depending on degree and age
▪ Typically involves outer myometrium of hemorrhage
o Occasionally subserosal ▪ Low- to intermediate-level echoes
o Rarely submucosal ▪ Less commonly hyperechoic
• Size ▪ May appear solid
o Variable o Peripheral rim
▪ 2-22 cm ▪ Ranges from slightly hypo- to slightly hyperechoic
• Morphology relative to myometrium
o Primarily round, ovoid, or lobulated • Color Doppler
▪ Less commonly multicystic o Wall shows increased vascularity
o Well-defined margins o Central portion is avascular, confirming cystic nature
o Thick wall
▪ May develop 2 zones Imaging Recommendations
– Inner and outer • Best imaging tool
▪ "Miniature uterus" due to resemblance to zonal o Transvaginal US
anatomy ▪ Initial modality
o Central cystic component with blood products in o MR
different stages of organization ▪ Highly accurate for making diagnosis and planning
▪ Fluid-fluid level may be present therapy
o Lesion demonstrates mass effect • Protocol advice
o Potential for rupture into endometrial cavity o Multiplanar high-resolution fast spin echo (FSE)
o Associated adenomyosis in remaining myometrium T2WI to demonstrate myometrial origin
present in some cases o T1WI without and with fat suppression to
demonstrate internal hemorrhage
CT Findings
• NECT
o Well-defined myometrial mass with internal DIFFERENTIAL DIAGNOSIS
hemorrhage
Leiomyoma With Hemorrhagic Degeneration
• CECT
• Typically more heterogeneous appearance
o Nonenhancing central cystic portion
o Thick enhancing wall • Less prominent rim or wall
MR Findings Leiomyoma With Fatty Degeneration
• T1WI FS • Signal loss on fat-suppressed T1WI
o Well-defined hyperintense myometrial mass • Chemical shift artifact on in- and opposed-phase
▪ Homogeneous high signal intensity represents imaging
subacute blood Müllerian Duct Anomaly
▪ No signal loss with fat suppression
o Rim isointense to myometrium
• Noncommunicating rudimentary horn
• T2WI
• Only 1 cornua identified in dominant horn
o Well-circumscribed, cystic myometrial mass Miscellaneous Uterine Cysts
o Central cystic portion • Congenital cysts (mesonephric/paramesonephric),
▪ Variable appearance depending on degree and age cervical nabothian cyst, echinococcal cyst
of hemorrhage o Simple cysts with thin walls
▪ Most commonly intermediate to high signal
intensity
▪ Less frequently hypointense relative to
PATHOLOGY
myometrium General Features
▪ Typically homogeneous but can be heterogeneous • Etiology 2
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Uterus CYSTIC ADENOMYOSIS
o Etiology of hemorrhage within implants of cystic • Myometrial excision of affected area with failure of
adenomyosis is not well understood medical treatment
▪ May represent sequela of cyclic hormonal changes o Occasionally supplemented with postexcision
– Hormonal receptors exhibiting some degree of hormonal therapy
proliferative and secretory changes have been • Successful radiofrequency ablation reported
identified in adenomyotic implants • Hysterectomy is definitive treatment
▪ May be result of spontaneous hemorrhage
▪ May be iatrogenic disruption of endomyometrial
barrier from prior surgery DIAGNOSTIC CHECKLIST
o Risk factors
Consider
▪ Prior uterine surgery
▪ Hormonal disturbances such as progestin therapy • Cystic adenomyosis in differential diagnosis
of endometrioma-like cystic mass arising from
▪ Chronic irritation due to intrauterine device
myometrium and surrounded by adenomyotic tissue
▪ Inflammation due to artery embolization
• Well-defined intramyometrial mass, with smooth or • Thick-walled, circumscribed, cystic myometrial mass
with internal hemorrhage
trabeculated white surface
• Exophytic cystic polypoid mass connected to uterus • Typically occur in outer myometrium
• Thick-walled cavities with brown staining of wall and • Normal uterine configuration with presence of both
cornua
surrounding myometrium, representing hemosiderin
and hemolyzed blood
SELECTED REFERENCES
• Single dominant cyst or multiple > 5 mm clefts filled 1. Jain N et al: Cystic Adenomyoma simulates uterine
malformation: a diagnostic dilemma: case report of two
with blood
• Endometrial glands lining cyst wall unusual cases. J Hum Reprod Sci. 5(3):285-8, 2012
2. Takeuchi M et al: Adenomyosis: usual and unusual imaging
o Main differentiating feature of cystic adenomyosis manifestations, pitfalls, and problem-solving MR imaging
from cystic degeneration of leiomyomas techniques. Radiographics. 31(1):99-115, 2011
o Smooth muscle and hyaline degeneration may occur, 3. Moyle PL et al: Nonovarian cystic lesions of the pelvis.
mimicking leiomyomas Radiographics. 30(4):921-38, 2010
o Uncommonly, focal squamous or mucinous 4. Ho ML et al: Adenomyotic cyst of the uterus in an
adolescent. Pediatr Radiol. 38(11):1239-42, 2008
epithelial metaplasia
• Hemosiderin-laden macrophages around cyst wall
5. Koga K et al: Images in reproductive medicine. A case of
giant cystic adenomyosis. Fertil Steril. 85(3):748-9, 2006
corresponding to low signal intensity on T2WI
•
6. Ryo E et al: Radiofrequency ablation for cystic adenomyosis:
Cyst wall composed of myometrial tissue a case report. J Reprod Med. 51(5):427-30, 2006
7. Imaoka I et al: Cystic adenomyosis with florid glandular
differentiation mimicking ovarian malignancy. Br J Radiol.
CLINICAL ISSUES 78(930):558-61, 2005
8. Tamai K et al: MR imaging findings of adenomyosis:
Presentation correlation with histopathologic features and diagnostic
• Most common signs/symptoms pitfalls. Radiographics. 25(1):21-40, 2005
o Pelvic pain ± palpable mass 9. Sakai Y et al: Large cystic uterine adenomyoma showing
• Other signs/symptoms marked epithelial metaplasia and exophytic polypoid
o Menorrhagia growth. Arch Gynecol Obstet. 269(1):74-6, 2003
10. Reinhold C et al: Uterine adenomyosis: endovaginal US
o Dysmenorrhea
and MR imaging features with histopathologic correlation.
o Abdominal cramps Radiographics. 19 Spec No:S147-60, 1999
o Abdominal distention and lower back pain during or 11. Kataoka ML et al: MRI of adenomyotic cyst of the uterus. J
after menstrual period Comput Assist Tomogr. 22(4):555-9, 1998
12. Troiano RN et al: Cystic adenomyosis of the uterus: MRI. J
Demographics Magn Reson Imaging. 8(6):1198-202, 1998
• Age
o More common in premenopausal, multiparous
women
• Epidemiology
o Rare

• Progressive increase in size due to periodic intracystic
secretion and bleeding
• Favorable prognosis
Treatment
• Initial medical management: Danazol, GnRH agonist
o Variable results from symptomatic relief to reduction
2 in cyst size
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CYSTIC ADENOMYOSIS
Uterus
(Left) Coronal oblique T2WI FSE
MR shows a homogeneously
hyperintense mass with
a thick hypointense wall .
This short-axis view of the
uterus demonstrates the outer
myometrial origin of the mass
to best advantage. Multiplanar
T2WI is indispensable when
localizing pelvic masses. (Right)
patient shows homogeneous
central hyperintensity of the
mass. The wall is not well seen as
it is isointense to myometrium on
this sequence. This is compatible
with cystic adenomyosis.

shows diffuse thickening of
the junctional zone in this
retroflexed uterus, compatible
with diffuse adenomyosis.
There is also a heterogeneous
myometrial mass with a thick
low-signal wall. Low signal
within the endometrial cavity is
compatible with blood products
due to rupture of the mass. Tiny
nabothian cysts are noted.
MR shows the communication
between the fundal mass and
endometrial cavity.

the internal heterogeneity of
the mass due to repeated
hemorrhage with blood
products of variable ages.
(Right) Axial T1WI FS MR shows
homogeneous marked internal
hyperintensity, confirming the
presence of internal hemorrhage
. The thick T2 hypointense
wall, deep myometrial location,
and internal hemorrhage
are consistent with cystic
adenomyosis with rupture into
the endometrial cavity.
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SECTION 3
Cervix

Cervical Anatomy 3-2
Infection/Inflammation
Cervical Stenosis 3-8
Benign Neoplasms
Endocervical Polyp 3-12
Cervical Leiomyoma 3-16
Malignant Neoplasms
Cervical Carcinoma 3-20
Adenoma Malignum 3-50
Cervical Sarcoma 3-54
Cervical Melanoma 3-58
Post-Trachelectomy Appearances 3-62
Miscellaneous
Cervical Glandular Hyperplasia 3-64
Nabothian Cysts 3-68
Obgyne Books Full

Cervix CERVICAL ANATOMY
▪ Cervix constitutes smaller proportion of uterine

TERMINOLOGY volume in premenopausal women
Synonyms ◦ After menopause, cervix constitutes greater
• Cervix uteri proportion of uterine volume as body atrophies
Definitions Histology
• • Endocervical canal lined by single layer of ciliated
Caudal segment of uterus that communicates with
vagina mucous-secreting columnar epithelium
◦ Epithelium organized in series of small V-shaped
GROSS ANATOMY folds (plicae palmatae)

◦ Underlying thin basement membrane
Overview • Ectocervix lined by stratified squamous epithelium
• Fibromuscular tubular portion of uterus that lies contiguous with vaginal mucosal lining
between uterine body and vagina • Squamocolumnar junction: Transitional zone between
◦ Originates at uterine isthmus (inferior narrowing of columnar and squamous epithelium
uterine body) and protrudes into superior vagina ◦ Near external os, but exact position is variable, under
• 2 segments continuous remodeling
◦ Supravaginal segment: Extends cranial to level of ◦ Site of development of cervical carcinoma
vagina • Underlying cervical stroma is highly fibrous, with high
▪ Includes internal cervical os, opening into uterine proportion of elastic fibers interwoven with smooth
cavity muscle
▪ Covered posteriorly by peritoneum ◦ Extracellular matrix contains collagen, elastin,
▪ Also called portio supravaginalis proteoglycans
◦ Vaginal segment (ectocervix): Extends into vaginal ◦ Cellular component contains smooth muscle cells
vault and fibroblasts
▪ Includes external cervical os, opening into ◦ Higher proportion of connective tissue at caudal/
vaginal lumen vaginal aspect of cervix, with higher proportion of
▪ Portion of cervix that extends into vagina is termed smooth muscle at proximal aspect
portio vaginalis ◦ Progressive decrease in collagen content throughout
▪ Surrounded by vaginal fornices pregnancy allows cervix to "soften" and dilate to
• Endocervical canal centrally positioned within cervix accommodate delivery of fetus
◦ Continuous with endometrial canal and vaginal • Numerous endocervical glands drain into endocervical
lumen canal
• Cervical size ◦ When obstructed/dilated, form nabothian cysts
◦ 2.5-3 cm in length in nongravid women
◦ Up to 6 cm in length in pregnancy IMAGING ANATOMY
◦ Cervical diameter is typically 3-4 cm
• Arterial supply: Dual vascular supply Overview
◦ Descending cervical branch of uterine artery • Cervix is routinely evaluated with US
◦ Superior branches of vaginal artery ◦ Cost-effective, widely available
• • MR imaging offers superior evaluation
Venous drainage
◦ Parametrial venous plexus → uterine vein → internal ◦ Excellent soft tissue contrast and multiplanar
iliac vein capabilities

• ◦ Preferred modality in tumor staging of cervical
Lymphatic drainage
◦ External iliac nodes (via broad ligament) carcinoma
◦ Internal iliac nodes
Anatomy Relationships
◦ Presacral nodes • Cervical positioning
• Innervation via inferior hypogastric (pelvic) plexuses ◦ Flexion describes positioning of uterine body relative
• Ligamentous support to cervix
◦ Pubocervical ligaments ▪ Most uteri are anteflexed
▪ Extend from anterior cervix to pubis ◦ Version describes axis of cervix relative to vagina
◦ Cardinal (transverse cervical) ligaments ▪ Most uteri are anteverted
▪ Extend from lateral cervix and vagina to pelvic • Cervix is extraperitoneal
sidewall
◦ Uterosacral ligaments MR
▪ Extend from posterior cervix and vagina to sacrum • T1WI: Uniform intermediate signal
• Age-related changes • T2WI: Zonal anatomy similar to uterine body
◦ Cervix increases in volume under hormonal ◦ Hyperintense central mucus/secretions in canal
stimulation until 5th decade then slowly decreases in ◦ High signal endocervical epithelial lining
volume ▪ Contiguous with endometrium
◦ Premenarche: Cervix and uterine body are roughly ▪ Plicae palmatae may be seen as separate
equal in size intermediate signal zone on high-resolution scans
◦ Uterine body grows significantly under hormonal ◦ Low signal inner cervical stroma, due to large
3 stimulation at puberty proportion of fibrous and elastic tissue

▪ Contiguous with junctional zone of uterine corpus
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CERVICAL ANATOMY
Cervix
◦ Outer layer of intermediate signal smooth muscle • Cervix and endocervical mucous help prevent
may be variably present ascending infection and maintain sterile endometrial
▪ Contiguous with outer myometrium environment
◦ Cervical zonal anatomy does not significantly change
in appearance throughout menstrual cycle
Cervical Pathology
• Cervix is susceptible to variety of conditions
• T1WI C+: Inner cervical mucosa enhances to greater
◦ Cervical stenosis
degree than cervical stroma
◦ Cervical incompetence
• Nabothian cysts are seen in > 50% of cases
◦ Cervicitis
◦ Represent obstructed, dilated cervical glands
◦ Cervical polyp
◦ Typically asymptomatic, incidental findings
◦ Glandular hyperplasia
◦ Low signal on T1WI, high signal on T2WI,
◦ Benign masses
nonenhancing, though can be variable in signal
▪ Nabothian cysts (very common)
Ultrasound ▪ Leiomyomata
• Cervix is well-evaluated on transabdominal and ◦ Primary malignancy
endovaginal imaging ▪ Cervical carcinoma
• Zonal anatomy of cervix can be visualized on US ▪ Adenoma malignum
◦ Fluid in endocervical canal: Anechoic linear stripe ▪ Other rare tumors
▪ Echogenic foci of air occasionally can be seen in ◦ Rare metastatic disease
endocervical canal
◦ Endocervical mucosa: Hyperechoic inner band EMBRYOLOGY
▪ Contiguous with endometrial echocomplex
◦ Inner cervical stroma: Hypoechoic middle band Embryologic Events
▪ Contiguous with junctional zone of uterine body • Uterus and upper vagina arise from paired
◦ Outer cervical stroma: Slightly echogenic outer band paramesonephric (müllerian) ducts
▪ Contiguous with outer uterine body myometrium ◦ Form lateral to mesonephric duct between 6-7 weeks
of gestation
CT • Caudal aspect of paramesonephric ducts fuse at midline
• Typically not preferred modality in uterine evaluation ◦ Fused inferior portion forms upper vagina and uterus
• NECT: Cervix is of homogeneous soft tissue density (body and cervix)
• CECT: Cervix may demonstrate targetoid enhancement ◦ Unfused superior segments empty into peritoneal
pattern, though variably present cavity, persist as fallopian tubes
◦ Central secretions/fluid: Hypodense ◦ Fusion abnormalities lead to müllerian duct
◦ Inner cervical mucosa: Intense enhancement
anomalies
◦ Inner stroma: Hypoenhancing ▪ Cervical duplication
◦ Outer stroma: Intermediate enhancement ▪ Cervical septation
◦ Cervix often displays diffuse hypoenhancement
compared to uterine body
• CECT useful in staging of cervical carcinoma RELATED REFERENCES
1. Wasnik AP et al: Normal and variant pelvic anatomy on
ANATOMY IMAGING ISSUES MRI. Magn Reson Imaging Clin N Am. 19(3):547-66; viii,
2011
Imaging Recommendations 2. Yitta S et al: Normal or abnormal? Demystifying uterine
• US: Cervix may be partially obscured on endovaginal and cervical contrast enhancement at multidetector CT.
evaluation secondary to probe placement in vaginal Radiographics. 31(3):647-61, 2011
3. Sajjad Y: Development of the genital ducts and external
fornix
genitalia in the early human embryo. J Obstet Gynaecol Res.
◦ Slightly retract probe to better visualize entire cervix
36(5):929-37, 2010
• MR: Multiplanar T2 imaging best demonstrated zonal 4. Hauth EA et al: MR imaging of the uterus and cervix in
anatomy healthy women: determination of normal values. Eur
◦ T1W C+ imaging useful for suspected malignancy Radiol. 17(3):734-42, 2007
5. Well D et al: Age-related structural and metabolic changes
Imaging Pitfalls in the pelvic reproductive end organs. Semin Nucl Med.
• Cervical pathology is often over-called on routine CT 37(3):173-84, 2007
imaging 6. Cunningham FG: Williams Obstetrics. 22nd ed. New York:
◦ Normal cervix may appear enlarged/prominent with McGraw-Hill, Medical Publishing Division, 2005
variable enhancement 7. Hoad CL et al: Uterine tissue development in healthy
women during the normal menstrual cycle and
investigations with magnetic resonance imaging. Am J
CLINICAL IMPLICATIONS Obstet Gynecol. 192(2):648-54, 2005
Clinical Importance 8. Okamoto Y et al: MR imaging of the uterine cervix: imaging-
pathologic correlation. Radiographics. 23(2):425-45; quiz
• Cervix acts as sphincter during pregnancy to retain 534-5, 2003
fetus within uterus 9. Ludmir J et al: Anatomy and physiology of the uterine
• Acts as conduit for sperm to enter uterus to fertilize cervix. Clin Obstet Gynecol. 43(3):433-9, 2000
ovum 10. Callen PW: Ultrasonography in Obstetrics and Gynecology.
3rd ed. Philadelphia: W.B. Saunders, 1994
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CERVICAL ANATOMY
Endocervical canal
Cervical epithelial lining

Internal cervical os
Posterior vaginal fornix

Vesicouterine pouch
Squamocolumnar junction
Fibromuscular cervical
stroma
External cervical os
Urinary bladder
Inner cervical stroma
Urinary bladder
Endocervical epithelium
Cardinal ligament
Uterosacral ligament
Rectum
(Top) Sagittal illustration of the uterine cervix demonstrates its relationship to other pelvic structures. The endocervical canal communicates with
the endometrial cavity at the level of the internal cervical os and with the vaginal lumen at the external os. The cervical fibromuscular stroma is
continuous with the myometrium, and the cervical epithelium is contiguous with the endometrium. At the external cervical os, the endocervical
columnar epithelium transitions to the ectocervical squamous epithelium at the squamocolumnar junction. (Bottom) Transverse illustration of the
cervix demonstrates the typical zonal anatomy, which accounts for the targetoid appearance on cross-sectional imaging. Note the uterosacral
and cardinal ligaments, which are major cervical support structures.
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CERVICAL ANATOMY
Cervix
CERVICAL ANATOMY, MR
Endometrial stripe Outer cervical stroma
Central secretions/mucous

Central endocervical secretions
Cervical stroma
Enhancing endocervical epithelium
Enhancing parametrial vasculature
(Top) Sagittal T2WI demonstrates typical cervical zonal anatomy. Central endocervical secretions are T2 hyperintense, with the endocervical
mucosal epithelium appearing intermediate in signal intensity. The inner cervical stroma is hypointense secondary to the prominent fibrotic
component. The outer cervical stroma, composed of smooth muscle, is intermediate in signal intensity. (Middle) Axial T2WI illustrates the
normal targetoid appearance of the cervix. Disruption of the dark inner cervical stromal band can be seen with an infiltrating cervical carcinoma.
(Bottom) Axial T1WI C+ FS through the cervix demonstrates a typical enhancement pattern. The endocervical epithelial lining enhances to a
greater degree than the cervical stroma, which appears relatively hypointense. The inner and outer cervical stromal layers are difficult to discern.
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CERVICAL ANATOMY, ULTRASOUND

Secretions/fluid in
endocervical canal
Shadowing fetal calvarium

within gravid uterus
Fluid in posterior vaginal

fornix outlining ectocervix
Focus of air within

endocervical canal
(Top) Longitudinal endovaginal ultrasound image of the cervix demonstrates a typical multilayered appearance, similar to that seen on MR.
Secretions within the endocervical canal appear as a central anechoic stripe. The endocervical epithelial lining appears slightly hyperechoic.
The inner cervical stroma is hypoechoic, whereas the outer stroma appears echogenic. (Bottom) Transverse endovaginal ultrasound image of
the cervix also shows a normal targetoid appearance. The cervix can be easily evaluated on routine ultrasound examinations, though it may be
partially obscured with probe placement in the vaginal fornix.
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CERVICAL ANATOMY
Cervix
CERVICAL ANATOMY, CT
Posterior endocervical
Endometrial stripe epithelium
Cesarean section scar

Secretions within
endocervical canal
Cervical stroma
Anterior endocervical
epithelium
Urinary bladder
Cervical stroma
Parametrial vasculature Fluid/secretions within

endocervical canal
(Top) Sagittal CECT image shows a typical appearance of the normal cervix. The epithelial lining of the endocervical canal enhances to a
greater degree than the underlying cervical stroma. The inner and outer cervical stromal layers are difficult to discern. Fluid/secretions within
the endocervical canal appear as a central hypoattenuating stripe. (Bottom) Axial CECT through the cervix demonstrates a typical targetoid
appearance, with enhancement of the endocervical epithelium and a hypodense appearance of the cervical stroma. Alternatively, the cervix may
demonstrate homogeneous hypoenhancement when compared to the uterine body.
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Cervix CERVICAL STENOSIS
Key Facts
Terminology • Cervix: Loss of normal zonal architecture if cervix has
• Cervical canal narrowing from benign or iatrogenic been irradiated or patient is postmenopausal (e.g.,
atrophy)
source; when severe, results in hydrometra, pyometra,
or hematometra Pathology
• Recognized common complication following
• Any process(es) that results in inflammation, erosion,
dilatation and curettage, radiation therapy to pelvis, repair, and regeneration of cervical mucosa
cone biopsy and cervical amputations, radical
trachelectomy
• In postmenopausal women, cervical stenosis is usually
•
due to atrophy
Cervical canal narrowing < 2.5-3 mm
Clinical Issues
Imaging • Dysmenorrhea in up to 50%
• Thickened cervix, fluid within endometrial canal on • Presents with inability to pass catheter, dilator, or
transvaginal ultrasound
• May see ancillary signs to suggest etiology of cervical
probe during sonohysterogram or biopsy
stenosis (e.g., thickened bowel associated with
• In women of reproductive age, may have retrograde
menses if patent fallopian tubes leading to
radiation therapy)
•
endometriosis and hemoperitoneum
May see dilated blood-filled fallopian tubes
(hematosalpinges)
• Dilation and evacuation of contents of dilated
endometrial canal

ultrasound image shows mild
distension of the endometrial
and endocervical cavity with
fluid in this patient with a
thickened echogenic cervix
due to prior instrumentation.
(Right) Longitudinal color
in a patient with benign
cervical stenosis shows fluid
distension of the endometrial
and endocervical cavity .
The endocervical cavity is
narrowed due to echogenic
thickening of the cervix
and relative internal
vascularity.

ultrasound centered on
the cervix shows marked
distension of the endocervical
cavity with low-level internal
echoes in this patient with
cervical stenosis from prior
instrumentation. (Right) Axial
with cervical stenosis shows
fluid distension of the cervical
cavity due to scarring from
prior dilatation and curettage
of prior pregnancy.
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CERVICAL STENOSIS
Cervix
Definitions Obstructed Uterus Secondary to Malignancy
• Cervical canal narrowing from benign or iatrogenic • Tumor of lower uterine segment or cervix
source
o When severe, results in hydrometra, pyometra, or
• Must always exclude tumor before ascribing cervical
stenosis to postmenopausal atrophy or other
hematometra nonmalignant etiologies in cases of thickened
• Defined as inability to pass 2.5-4.5 mm probe through endometrium
cervical os
Obstructed Uterus Secondary to Mass Effect
IMAGING
• Cervical or submucosal leiomyoma or other pelvic mass
causing compression/obstruction of endocervical canal
General Features • Mass effect may be due to inflammation in lower
• Best diagnostic clue uterine tract or cervix in case of infection
o Thickened cervix, fluid within endometrial canal on Congenital Anomalies
transvaginal ultrasound • Includes imperforate hymen, complete transverse
vaginal septum, cervical atresia, vaginal atresia
CT Findings
• CECT • In case of uterine duplication anomalies with an
obstructed horn, blood-filled horn may be mistaken for
o Hydrometra or hematometra may be seen uterus and other horn may be missed
▪ Normal-appearing cervix and uterus distended
• May have associated hematocolpos and hematometra
with simple fluid or blood
– May see ancillary signs to suggest etiology
• Kidneys should also be evaluated for associated
anomalies
of cervical stenosis (e.g., thickened bowel
associated with radiation therapy)
– May see dilated, blood-filled fallopian tubes PATHOLOGY
(hematosalpinges)
General Features
MR Findings • Etiology
• T1WI o Any process(es) that results in inflammation, erosion,
o Cervix: Normal morphology and signal intensity (SI) repair, and regeneration of cervical mucosa
(isointense to myometrium) o Organic causes
o Uterine corpus: Enlarged; SI of cavity reflects ▪ Senile atrophy
contents – Usual cause in postmenopausal women
▪ Simple endometrial fluid (hydrometra): Low SI ▪ Chronic infection
▪ Hematometra: Intermediate to high SI ▪ Tumor (controversy whether term "cervical
• T2WI stenosis" should be reserved for cases of cervical
o Cervix: Loss of normal zonal architecture if cervix narrowing that are not result of mass effect by
has been irradiated or the patient is postmenopausal tumor upon endocervical canal)
(e.g., atrophy) o Iatrogenic causes
o Uterine corpus: Myometrium and junctional zone ▪ Radiation therapy
may be thinned by distended endometrial canal; ▪ Laser or cryosurgery
fluid may vary in SI depending on type of fluid ▪ Loop electrocautery excision
▪ Simple fluid: High SI ▪ Cervical endometriosis (most frequently seen after
▪ Proteinaceous fluid (to include blood): combined cervical conization and endometrial
Intermediate to low SI curettage)
• T1WI C+ ▪ Other cervical interventions
o Cervix typically enhances as myometrium does • Pathology reflects etiology (e.g., atrophy vs. post
instrumentation)
Ultrasonographic Findings • Blood passage through endocervical canal
• Grayscale ultrasound helps prevent obliteration of canal after cone
o Normal-appearing or thick endocervix biopsy; therefore, stenosis is more common in
o Uterine or cervical canal maybe distended with fluid nonmenstruating patients
o May present with inability to pass catheter during • Atrophy-related decrease in endocervical glands results
sonohysterography in decreased secretion of mucus, which is also thought
to help keep canal open
Imaging Recommendations o Similar mechanism is implicated in endocervical
• Best imaging tool gland removal after cone biopsy or surgery
o Transvaginal sonography is initial modality to
evaluate pelvic pathology
• Conization results in cervical stenosis due to adherence
of walls of exposed stromal surfaces
▪ MR or CT for ancillary findings to suggest etiology
of cervical stenosis Microscopic Features
• Inflammation, erosion, repair, and regeneration share
histologic features
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Cervix CERVICAL STENOSIS
• Collapse and juxtaposition of exposed cervical stroma o Interruption of uterine flow with resultant secondary
is at increased risk of adhesion; lack of structural complications from fluid collection
integrity is more pronounced as length of central tissue o Inability to pass endometrial biopsy catheter to
removed increases obtain endometrial sample for cancer screening
o Inability to assess endocervix by Papanicolaou smear
in patients with previous history of cervical dysplasia
CLINICAL ISSUES
Presentation DIAGNOSTIC CHECKLIST
o Dysmenorrhea in up to 50% Image Interpretation Pearls
o Menstrual disturbance • Cervix appears normal or thickened
o Cyclical pain if causing hematometra and bilateral • With severe stenosis, endometrial cavity is dilated with
hematosalpinx marked hydrometra, pyometra, or hematometra
o Presents with inability to pass catheter, dilator, or
probe during sonohysterogram or biopsy
SELECTED REFERENCES
o Infection due to fluid collection of mucus &/or blood 1. Jain D: An unusual case of secondary amenorrhoea. BMJ
• Pain and cramping from endometrial cavity distension Case Rep. 2013, 2013
•
2. Noor C et al: An unusual case of hematometra in a
May present with sense of fullness in pelvis, or with postmenopausal woman associated with Manchester repair.
suprapubic palpable tender mass J Low Genit Tract Dis. 16(2):162-4, 2012
• Urinary retention and constipation may occur because 3. Cicchiello LA et al: Ultrasound evaluation of gynecologic
of compression of distended uterus causes of pelvic pain. Obstet Gynecol Clin North Am.
• Women of reproductive age may have retrograde
4.
38(1):85-114, viii, 2011
Walid MS et al: An invisible stenotic cervix. Arch Gynecol
menses; if fallopian tubes are patent, they may lead to
Obstet. 283 Suppl 1:121-2, 2011
endometriosis and hemoperitoneum
• Inadequate follow-up after surgical correction may
5. Opolskiene G et al: Three-dimensional ultrasound imaging
for discrimination between benign and malignant
result in an increased risk of recurrent cervical dysplasia endometrium in women with postmenopausal bleeding
or cancer and sonographic endometrial thickness of at least 4.5 mm.
• May lead to problems with endometrial sampling in Ultrasound Obstet Gynecol. 35(1):94-102, 2010
patients with dysfunctional uterine bleeding 6. Borgatta L et al: Cervical obstruction complicating second-
• May lead to in vitro fertilization failure trimester abortion: treatment with misoprostol. Obstet
• Precludes most major procedures that require use of
7.
Gynecol. 113(2 Pt 2):548-50, 2009
Diedrich J et al: Complications of surgical abortion. Clin
scopes (> 9 mm)
•
Obstet Gynecol. 52(2):205-12, 2009
May lead to uterine infections 8. Steinkeler JA et al: Female infertility: a systematic approach
to radiologic imaging and diagnosis. Radiographics.
Demographics
• Epidemiology
29(5):1353-70, 2009
9. Christianson MS et al: Overcoming the challenging cervix:
o 20% of patients with history of in utero exposure to techniques to access the uterine cavity. J Low Genit Tract
diethylstilbestrol Dis. 12(1):24-31, 2008
o Endometriosis commonly coexists in women with 10. Grund D et al: A new approach to preserve fertility by using
stenosis and pelvic pain a coated nitinol stent in a patient with recurrent cervical
stenosis. Fertil Steril. 87(5):1212, 2007
Natural History & Prognosis 11. McCausland AM et al: Long-term complications of
• If not severe, egress of endometrial fluids is not endometrial ablation: cause, diagnosis, treatment, and
prevention. J Minim Invasive Gynecol. 14(4):399-406, 2007
hampered
• If severe, progressive uterine obstruction with 12. Tan Y et al: Urinary catheter stent placement for treatment
of cervical stenosis. Aust N Z J Obstet Gynaecol. 47(5):406-9,
endometrial cavity dilation (hydrometra/ 2007
hematometra) 13. Van den Bosch T et al: A thin and regular endometrium on
• Some cases resolve spontaneously ultrasound is very unlikely in patients with endometrial
malignancy. Ultrasound Obstet Gynecol. 29(6):674-9, 2007
Treatment 14. Debby A et al: Intra-uterine fluid collection in
• Dilation and evacuation of contents of dilated postmenopuasal women with cervical stenosis. Maturitas.
endometrial canal 55(4):334-7, 2006
o Sampling is mandatory in postmenopausal women 15. Hammoud AO et al: Ultrasonography-guided transvaginal
with thickened peripheral endometrium endometrial biopsy: a useful technique in patients with
o Can be performed with successively larger dilators cervical stenosis. Obstet Gynecol. 107(2 Pt 2):518-20, 2006
16. Newman C et al: Hysterectomy in women with cervical
of with dilation with angioplasty balloon under stenosis. Surgical indications and pathology. J Reprod Med.
fluoroscopic guidance
•
48(9):672-6, 2003
Catheter placement if long-term drainage is required 17. Houlard S et al: Risk factors for cervical stenosis after laser
• Laminaria tent (seaweed derivative; natural cervical cone biopsy. Eur J Obstet Gynecol Reprod Biol. 104(2):144-7,
dilator) is inserted into cervix 2002
• Hysteroscopic excision of cervical tissue 18. Ohara N: Acute onset of hematometra associated with
• Hysterectomy is considered in following circumstances

endometritis and cervical stenosis. A case report. Clin Exp
Obstet Gynecol. 29(1):23-4, 2002
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CERVICAL STENOSIS
Cervix
(Left) Axial CECT centered in
the pelvis of a young female
with benign cervical stenosis,
who presented with pelvic
fullness, demonstrates marked
dilatation of the endometrial
cavity with fluid and resultant
thinning of myometrium .
(Right) Longitudinal ultrasound
image of the uterus in the same
patient with cervical stenosis
and hematometra shows the
distension of the endocervical
echoes and abrupt caliber
change to normal-appearing
cervix .

image of the uterus shows
thickening and distension
of the endometrial cavity
with hyperechoic fluid
corresponding to hematometra
in this patient with longstanding
cervical stenosis due to cone
biopsy of the cervix. (Right)
distension of the cervical cavity
with fluid containing low-level
internal echoes .

woman with pelvic pain
demonstrates distension of
the endometrial cavity with a
hypoechoic structure containing
low-level internal echoes ,
with normal echogenicity of the
cervix . Hysteroscopy proved
benign cervical stenosis due to
prior dilatation and curettage.
hematometra with hypoechoic
fluid distending the endometrial
cavity .
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Cervix ENDOCERVICAL POLYP
Key Facts
Imaging o May not be visualized due to coaptation of cervix;
• Small pearl-shaped mass applying moderate amount of gel to transducer may
• Central feeding vessel in stalk can be seen with color be useful as "contrast" agent
o May be outlined by fluid
flow imaging
• Originates from cervical canal and may protrude Pathology
through external os • May be related to tamoxifen use
• Can originate in endometrial canal and prolapse into • Other suggested etiological factors in the development
endocervical canal
• Gigantic polyps are rare
of cervical polyps include
o Multiparity
• Usually pedunculated o Chronic cervicitis
• Transvaginal ultrasound (TVUS) o Foreign bodies
o Echogenic mass within endocervical canal o Estrogen secretion
o Thickening of endocervical canal ± cystic change
o Often difficult to detect sonographically because Clinical Issues
endocervical polyps are indistinguishable from • Hysteroscopy and curettage for treatment
cervical mucosa
o May contain cystic spaces

ultrasound image in a 36
year old who presented
with intermittent vaginal
spotting demonstrates an
echogenic oval mass within
the endocervical cavity with
small internal cystic regions
. Hysteroscopy proved it
to be a benign endocervical
polyp. (Right) Transverse
color Doppler transvaginal
ultrasound shows intense
linear vascularity within
the vascular stalk of the
pedunculated endocervical
polyp .
(Left) AP view from

hysterosalpingogram in a
38 year old presenting with
infertility demonstrates a large
filling defect narrowing and
displacing the endocervical
cavity . (Right) Sagittal
patient shows the defect to be
a low signal polypoid mass
cavity. Hysteroscopic resection
proved to be a benign
endocervical polyp.
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ENDOCERVICAL POLYP
Cervix
o May be outlined by fluid
TERMINOLOGY o Smoothly marginated mass projecting off of stalk
Synonyms • Can demonstrate vascular flow
• Cervical polyp Imaging Recommendations
IMAGING o TVUS
▪ Sonohysterogram
General Features
o Use color flow to look for central vessel in stalk
o Small pearl-shaped mass o Applying generous amount of gel to transducer may
o Feeding vessel in stalk can be seen with color flow
be useful as "contrast agent"
imaging
• Location
o Originates from cervical canal and may protrude DIFFERENTIAL DIAGNOSIS
through external os
▪ Can originate in endometrial canal and prolapse
Cervical Malignancy
into endocervical canal • Cannot differentiate cervical polyp harboring
• Size
noninvasive cancer from purely benign polyp
• Cervical malignancy may invade underlying cervical
o Usually measures between 2-30 mm but can reach
tissue vs. benign polyp without invasion
larger sizes and protrude beyond vulva
o Gigantic polyps are rare Cervical Leiomyoma
• Morphology • 10% of leiomyomas are cervical
o Usually pedunculated • Usually grows submucosally or subserosally but may be
polypoid
CT Findings
• CECT Blood Clot
o Soft tissue mass can be seen similar to attenuation of • No internal vascularity, will not enhance following
uterine myometrium contrast
MR Findings • Transvaginal passage of blood clot over short period of
time
• T1WI Endometrial Polyp or Leiomyoma
o Low-signal intensity fluid within cystic spaces of
polyp • Leiomyomas can be large enough to prolapse through
• T2WI external cervical os
o Low signal intensity endocervical mass surrounded • Tend to be polypoid with broad base
by high signal intensity fluid, or large multicystic • Doppler imaging may be useful to detect and
mass with high signal intensity fluid, filling demonstrate feeding vessel and thus stalk extending
endocervical canal through endocervical canal and originating from
• DWI intrauterine location
o Usually does not restrict diffusion Sarcoma Botryoides
• T1WI C+ • Cervical involvement is exceedingly rare with majority
o Brisk enhancement reported in adolescents
▪ Similar enhancement and signal to that of uterine
myometrium Müllerian Adenosarcoma
• Extremely rare aggressive variant of müllerian mixed
mesodermal tumor of uterus
• Grayscale ultrasound Uterine Epithelioid Endometrial Stromal
o Echogenic mass within endocervical canal
▪ Thickening of the endocervical canal ± cystic Sarcoma
change • Rare
o Often difficult to detect sonographically because
endocervical polyps are indistinguishable from
cervical mucus
PATHOLOGY
• Transvaginal ultrasound (TVUS) General Features
o Central feeding vessel in stalk on color flow imaging
o Well-defined echogenic structure in endocervix
• Etiology
o May be related to tamoxifen use
o May or may not prolapse through external os into o Other suggested etiological factors in development of
vaginal canal cervical polyps include
o May be surrounded by fluid ▪ Multiparity
o May contain cystic spaces ▪ Chronic cervicitis
o May not be visualized due to coaptation of cervix; ▪ Foreign bodies
applying moderate amount of gel to transducer may ▪ Estrogen secretion
be useful as "contrast agent" • Focal, hyperplastic protrusions of endocervical folds
• Sonohysterography (epithelium and substantia propria) 3
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Cervix ENDOCERVICAL POLYP
• Develop dysplasia and in situ or invasive carcinoma in Treatment

< 1% • Hysteroscopy and curettage for treatment
• Usually pedunculated with pedicle of varying length DIAGNOSTIC CHECKLIST
• May be sessile
• Soft, smooth red or purple, few millimeters to 3 cm Consider
• Must always consider endometrial polyp when mass is
Microscopic Features seen prolapsing through cervix
• Variety of patterns that are classified according to Image Interpretation Pearls
• Isoechoic to myometrium with feeding vessel
preponderance of tissue component
o Endocervical mucosal: Most common polyp,
demonstrated on color Doppler imaging
• May have cystic change within polyp
composed of hyperplastic endocervical epithelium
o Fibrous
o Vascular
o Mixed endocervical and endometrial
SELECTED REFERENCES
o Mesodermal stromal
• Cystically dilated endocervical glands 1. Long ME et al: Comparison of dysplastic and benign
•
endocervical polyps. J Low Genit Tract Dis. 17(2):142-6,
Large number of blood vessels at surface 2013
• Inflammatory infiltrate in 80% of cases 2. McCluggage WG: New developments in endocervical
glandular lesions. Histopathology. 62(1):138-60, 2013
CLINICAL ISSUES leiomyomas before and after embolization. Radiographics.
32(6):E251-81, 2012
Presentation 4. Allison SJ et al: saline-infused sonohysterography: tips for
• Most common signs/symptoms achieving greater success. Radiographics. 31(7):1991-2004,
o Generally asymptomatic 2011
o 40% are symptomatic 5. Dasgupta S et al: Ultrasound assessment of endometrial
o Vaginal spotting cavity in perimenopausal women on oral progesterone
for abnormal uterine bleeding: comparison of diagnostic
accuracy of imaging with hysteroscopy-guided biopsy. J
o Menometrorrhagia Obstet Gynaecol Res. 37(11):1575-81, 2011
o Contact bleeding 6. Steinkeler JA et al: Female infertility: a systematic approach
o Vaginal discharge to radiologic imaging and diagnosis. Radiographics.
o Can be misdiagnosed as miscarriage in early 29(5):1353-70, 2009
pregnancy when significant bleeding occurs 7. Yi KW et al: Giant endocervical polyp mimicking cervical
o Can grow significantly in pregnancy and even malignancy: primary excision and hysteroscopic resection. J
Minim Invasive Gynecol. 16(4):498-500, 2009
increase massively intrapartum 8. Makris N et al: Three-dimensional hysterosonography
o Bleeding in postpartum period can be a problem versus hysteroscopy for the detection of intracavitary
due to their vascularity and can be misdiagnosed as uterine abnormalities. Int J Gynaecol Obstet. 97(1):6-9,
retained products 2007
• Clinical profile 9. Stamatellos I et al: The role of hysteroscopy in the current
o One of the most common causes of intermenstrual management of the cervical polyps. Arch Gynecol Obstet.
276(4):299-303, 2007
vaginal bleeding
10. Goh SG et al: Uterine epithelioid endometrial stromal
▪ Common cause of postmenopausal bleeding and sarcoma presenting as a "cervical polyp". Ann Diagn Pathol.
frequently seen in patients taking tamoxifen 9(2):101-5, 2005
▪ Accounts for 60% of endocervical polypoid lesions 11. Robertson M et al: Endocervical polyp in pregnancy: gray
o Can be seen on speculum examination when scale and color Doppler images and essential considerations
protruding through external os and may even be in pregnancy. Ultrasound Obstet Gynecol. 26(5):583-4, 2005
palpated on vaginal examination 12. Park HM et al: Mullerian adenosarcoma with sarcomatous
overgrowth of the cervix presenting as cervical polyp: a case
Demographics report and review of the literature. Int J Gynecol Cancer.
• Age 14(5):1024-9, 2004
o Found in perimenopausal (4th-5th decades) 13. Tang H et al: An intrapartum giant cervical polyp. N Z Med J.
117(1206):U1181, 2004
multiparous women
•
14. Okamoto Y et al: MR imaging of the uterine cervix: imaging-
Epidemiology pathologic correlation. Radiographics. 23(2):425-45; quiz
o Constitute up to 10% of all cervical lesions 534-5, 2003
15. Williams PL et al: US of abnormal uterine bleeding.
• Excellent, even if polyp harbors carcinoma that is
Radiographics. 23(3):703-18, 2003
16. Nalaboff KM et al: Imaging the endometrium: disease and
confined to polyp normal variants. Radiographics. 21(6):1409-24, 2001
o Carcinomatous changes are reported in 1.7% of
cervical polyps
• Atypical hyperplasia and endometrial adenocarcinoma
has been found in cervical polyps, usually symptomatic
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ENDOCERVICAL POLYP
Cervix
ultrasound image shows a
pedunculated endocervical
polyp surrounded with fluid
internal vascularity within the
polypoid endocervical mass.

41-year-old woman presenting
with postcoital bleeding
demonstrates a hypointense
polypoid mass expanding
the endocervical cavity.
Hysteroscopy resection proved
to be a benign endocervical
polyp. (Right) Axial T1WI C+ FS
avid enhancement of the polyp
similar to the myometrium
with small internal cystic change
.

ultrasound image in 44-year-old
woman with vaginal spotting
demonstrates expansion of
the endocervical cavity due
to a large echogenic mass
with internal cystic change
. Hysteroscopy proved the
mass to be a large endocervical
polyp. (Right) Longitudinal color
Doppler transvaginal ultrasound
image shows vascularity of the
fibrovascular stalk of the
polyp noted to course along the
prolapsing endocervical polyp
from the endometrial cavity.
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Cervix CERVICAL LEIOMYOMA
Key Facts
Terminology • MR reserved for equivocal or nondiagnostic cases
• Benign smooth muscle tumor of cervix o Establish diagnosis, size, number, and location of
leiomyoma
Imaging
• Homogeneous, round, well-defined cervical mass Pathology
• Hormonally responsive
• May be submucosal, intramural, or subserosal • Estrogen stimulates, often increase in size during
• When large, submucosal, and pedunculated, may pregnancy and with birth control pills
prolapse into vagina or into uterine cavity
• MR Clinical Issues
o T1WI: Hypo- or isointense to smooth muscle (unless
• Bleeding, pressure on adjacent organs, pain, infertility
degenerated)
o T2WI: Homogeneous and hypointense to cervical
• Associated with habitual abortion
• Increased incidence in African Americans
•
smooth muscle
• Up to 10% of all leiomyomas are cervical
• Uterine artery embolization: Cervical leiomyomas
US
o May cause posterior attenuation of sound
o Feeding vessel can be traced to cervix when tend to be refractory
pedunculated
o Primary modality to diagnose and evaluate

ultrasound image of the uterus
shows a large, echogenic mass
cavity corresponding to a
large cervical leiomyoma,
which was surgically resected.
ultrasound centered in
the cervix shows a large
echogenic mass replacing
the endocervical cavity.
There are central regions
of hypoechogenicity
degenerations.

of the pelvis in a 46-year-
with vaginal bleeding shows a
large, relatively T2-isointense
round mass replacing the
cervix with central regions
of T2 hyperintensity
degeneration in this large
cervical leiomyoma, which
was confirmed on surgical
resection. (Right) Axial
T2WI FSE MR of a cervical
leiomyoma shows a mass
replacing the cervix with
regions of T2 hyperintensity
due to degeneration.
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CERVICAL LEIOMYOMA
Cervix
o Color Doppler demonstrates "draping vessel"
TERMINOLOGY
pattern with vessels surrounding and penetrating
Synonyms leiomyoma, and relative lack of central vascularity
• Cervical fibroma, myoma o Feeding vessel can be traced to cervix when
pedunculated
Definitions
• Benign smooth muscle tumor of cervix Angiographic Findings
• Conventional
o Uterine vessels maybe seen feeding cervical
IMAGING leiomyoma
General Features Other Modality Findings
• Best diagnostic clue • Hysterosalpingogram: May have mass effect on
o Homogeneous, round, well-defined cervical mass endocervical canal
• Location
o Arises within or from cervix
o May be submucosal, intramural, or subserosal • US is primary modality to diagnose and evaluate
o When large, submucosal, and pedunculated, may • May miss cervical leiomyoma if US transducer is
positioned too far anteriorly
• MR reserved for equivocal or nondiagnostic cases
prolapse into vagina or into uterine cavity
Radiographic Findings o Establish diagnosis, size, number, and location of
• Radiography leiomyoma
o Coarse calcifications visible if degenerated o Help select patients for invasive treatment
o Used for monitoring
CT Findings
• NECT
o Homogeneous attenuation similar to myometrium DIFFERENTIAL DIAGNOSIS
o May see calcifications &/or cystic necrosis if
Malignant Cervical Neoplasms
• Irregular morphology and not well demarcated,
degenerated
• CECT
especially if invasive in cases of malignancy
o Initially enhances less than myometrium on arterial
phase imaging • May see extension beyond confines of cervix into lower
o May be isodense to myometrium on delayed images uterine segment, bladder, or rectum
• Heterogeneous echogenicity or signal intensity
MR Findings • Increased vascularity centrally
• T1WI Endocervical Polyp
o Hypo- or isointense to smooth muscle (unless
degenerated) • Protrude into endocervical canal and may mimic
• T1WI FS pedunculated, submucosal, cervical leiomyoma
• Usually isoechoic to endometrium
o Isointense; hyperintense if hemorrhagic
degeneration • Often have cystic spaces; must be differentiated from
• T2WI cervical leiomyoma with cystic degeneration
• May see feeding vessel
o Homogeneous and hypointense to cervical smooth
muscle Pedunculated Uterine Leiomyoma
▪ Degenerated: Heterogeneous with high T2 signal • If subserosal, may extend posterior to cervix
intensity (SI) areas
▪ Pseudocapsule of compressed normal smooth
• If submucosal, may prolapse into endocervical canal
muscle
• Evaluation of vascular supply or identification of stalk/
pedicle may help determine origin
▪ Hyperintense rim of edema and dilated lymphatics
and veins
▪ If cellular histology, may have high SI PATHOLOGY
• T1WI C+
General Features
o Most leiomyomas enhance post contrast
▪ Degenerated areas may not enhance • Etiology
o Etiology unclear
Ultrasonographic Findings o Sex steroid hormones influence growth
• Grayscale ultrasound ▪ Estrogen stimulates; progesterone inhibits growth
o Well-defined, hypoechoic mass • Genetics
• Color Doppler o No hereditary factor clearly identified
o Internal vascularity present • Leiomyomas: Most common uterine neoplasm
• Transvaginal ultrasound (TVUS) • Cervical leiomyomas are uncommon: 8-10% of all
o Homogeneous hypoechoic mass if not degenerated leiomyomas
o May cause posterior attenuation of sound • Well-defined, pseudocapsulated mass of cervix
o Heterogeneous ± calcification if degenerated
o Demonstrate internal vascularity on Doppler or color
• Grossly and histologically identical to those found in
flow US
uterine corpus
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Cervix CERVICAL LEIOMYOMA
• Hormonally responsive Treatment

o Estrogen stimulates; often increase in size during • Definitive: Hysterectomy
pregnancy and with birth control pills
o Progesterone inhibits; often decrease in size with
• Uterine sparing alternatives
o Medical therapy: Gonadotropin-releasing hormone
menopause analog
Staging, Grading, & Classification ▪ Regrowth after cessation of treatment
• Classified according to location o Myomectomy: Up to 15% may recur
▪ Increased surgical difficulty because of proximity
Gross Pathologic & Surgical Features to bladder and relative inaccessibility
• Spherical, firm, white, and elastic in consistency o Uterine artery embolization: Cervical leiomyomas
• Whorled bundles of smooth muscle separated by tend to be refractory
connective tissue stroma
Microscopic Features DIAGNOSTIC CHECKLIST
• Uniform, anastomosed, and whorled smooth muscle
Consider
• Mass arising from bladder, rectum, or lower uterine
cells
• Variable amounts of fibrous connective tissue and
segment
small, rare blood vessels
CLINICAL ISSUES • Should search for point of origin to establish whether
cervical or uterine
Presentation • Doppler may assist with search for vascular supply
o Most leiomyomas are asymptomatic
o When symptomatic, 4 major types of symptoms SELECTED REFERENCES
▪ Bleeding 1. Koesters C et al: Uterine artery embolization in single
▪ Pressure on adjacent organs symptomatic leiomyoma: do anatomical imaging criteria
▪ Pain predict clinical presentation and long-term outcome? Acta
Radiol. 55(4):441-9, 2014
▪ Infertility 2. Deshmukh SP et al: Role of MR imaging of uterine
o Cervical leiomyomas are associated with habitual leiomyomas before and after embolization. Radiographics.
abortion 32(6):E251-81, 2012
o Rare complications 3. Kim MD et al: Limited efficacy of uterine artery
▪ Torsion embolization for cervical leiomyomas. J Vasc Interv Radiol.
▪ Infection 23(2):236-40, 2012
▪ Malignant degeneration 4. Allison SJ et al: saline-infused sonohysterography: tips for
o Often degenerated if > 5-8 cm (carneous, hyaline, achieving greater success. Radiographics. 31(7):1991-2004,
2011
fatty, cystic, calcific)
•
5. Hori M et al: Uterine tumors: comparison of 3D versus 2D
In pregnant patients, may cause T2-weighted turbo spin-echo MR imaging at 3.0 T--initial
o Spontaneous abortion experience. Radiology. 258(1):154-63, 2011
o Premature labor 6. Pérez Colon L et al: Profuse vaginal bleeding in an
o Obstructed labor necessitating cesarean section adolescent with a cervical myoma: a case report. Bol Asoc
• Anemia Med P R. 103(2):65-6, 2011
• Pelvic mass
7. Straub HL et al: Cervical and prolapsed submucosal
leiomyomas complicating pregnancy. Obstet Gynecol Surv.
• If exerting enough mass effect on lower uterine 65(9):583-90, 2010
segment, may cause obstruction with resulting 8. Liapi E et al: Assessment of response of uterine fibroids
hematometra or hydrometra and myometrium to embolization using diffusion-
weighted echoplanar MR imaging. J Comput Assist Tomogr.
Demographics 29(1):83-6, 2005
• Epidemiology 9. Suneja A et al: Incarcerated procidentia due to cervical
o Cervical leiomyomas comprise up to 10% of all fibroid: an unusual presentation. Aust N Z J Obstet
leiomyomas Gynaecol. 43(3):252-3, 2003
o Increased incidence in African Americans 10. Varras M et al: Clinical considerations and sonographic
findings of a large nonpedunculated primary cervical
o Incidence between 0.6% and 2%
leiomyoma complicated by heavy vaginal haemorrhage:
Natural History & Prognosis a case report and review of the literature. Clin Exp Obstet
• Hormonally responsive Gynecol. 30(2-3):144-6, 2003

o Grow during reproductive years, especially
pregnancy
o Decrease in size with menopause or induced
hypoestrogenic state
o Rapid unexpected growth may indicate malignant
transformation
• Good; most women are asymptomatic
3 • If symptomatic, most women benefit from treatment
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CERVICAL LEIOMYOMA
Cervix
centered at the uterus shows a
large, heterogeneous mass
replacing the cervix, which is
predominantly isointense to the
uterine myometrium containing
linear T2-hypointense regions
degeneration in this pathology-
proven cervical leiomyoma.
in the same patient shows avid
enhancement of the cervical
leiomyoma.

menorrhagia shows a large,
well-defined, T2 homogeneous
hypointense mass centered
in the uterine cervix. Surgical
resection proved to be a benign
leiomyoma of the cervix. (Right)
same patient with a leiomyoma
of the cervix shows the large,
T2-hypointense myoma
replacing the uterine cervix.

scanned in the early arterial
phase shows mild enhancement
of the cervical myoma; however,
the fibroid shows relative T1
post-contrast hypointensity
centrally . (Right) Sagittal
T1WI C+ FS MR of the cervical
leiomyoma performed on the
venous phase shows dense
delayed enhancement of the
myoma with a classic "whorled"
appearance of the fibroid
stroma.
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Cervix CERVICAL CARCINOMA

(T) Primary Tumor
T1 I Cervical carcinoma confined to uterus (extension to corpus should be disregarded)
T1a² IA Invasive carcinoma diagnosed only by microscopy; stromal invasion with a maximum
depth of 5.0 mm measured from base of epithelium and a horizontal spread of ≤ 7.0 mm;
vascular space involvement, venous or lymphatic, does not affect classification
T1a1 IA1 Measured stromal invasion ≤ 3.0 mm in depth and ≤ 7.0 mm in horizontal spread
T1a2 IA2 Measured stromal invasion > 3.0 mm and ≤ 5.0 mm with a horizontal spread ≤ 7.0 mm
T1b IB Clinically visible lesion confined to cervix, or microscopic lesions greater than T1a/IA2
T1b1 IB1 Clinically visible lesion ≤ 4.0 cm in greatest dimension
T1b2 IB2 Clinically visible lesion > 4.0 cm in greatest dimension
T2 II Cervical carcinoma invades beyond uterus but not to pelvic wall or to lower 1/3 of vagina
T2a IIA Tumor without parametrial invasion
T2a1 IIA1 Clinically visible lesion ≤ 4.0 cm in greatest dimension
T2a2 IIA2 Clinically visible lesion > 4.0 cm in greatest dimension
T2b IIB Tumor with parametrial invasion
T3 III Tumor extends to pelvic wall &/or involves lower 1/3 of vagina, &/or causes
hydronephrosis or nonfunctioning kidney
T3a IIIA Tumor involves lower 1/3 of vagina, no extension to pelvic wall
T3b IIIB Tumor extends to pelvic wall &/or causes hydronephrosis or nonfunctioning kidney
T4 IVA Tumor invades mucosa of bladder or rectum, &/or extends beyond true pelvis (bullous
edema is not sufficient to classify a tumor as T4)
(N) Regional Lymph Nodes

N1 IIIB Regional lymph node metastasis

M1 IVB Distant metastasis (including peritoneal spread, involvement of supraclavicular,
mediastinal, or paraaortic lymph nodes, lung, liver, or bone)

²All macroscopically visible lesions, even with superficial invasion, are T1b/IB.
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CERVICAL CARCINOMA
Cervix
Stage T N M
0 Tis N0 M0
I T1 N0 M0
IA T1a N0 M0
IA1 T1a1 N0 M0
IA2 T1a2 N0 M0
IB T1b N0 M0
IB1 T1b1 N0 M0
IB2 T1b2 N0 M0
II T2 N0 M0
IIA T2a N0 M0
IIA1 T2a1 N0 M0
IIA2 T2a2 N0 M0
IIB T2b N0 M0
III T3 N0 M0
IIIA T3a N0 M0
IIIB T3b Any N M0
T1-3 N1 M0
IVA T4 Any N M0
IVB Any T Any N M1
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Methods for Microscopic

Tis Measurement of Depth of Invasion
H&E stain shows a high-grade squamous intraepithelial lesion. (A) The depth of invasion is measured from the origin of invasion
Cells have hyperchromatic nuclei, lack maturation, lack normal to the last cell of the invasion focus. (B) Invasion is measured from
organization, and show indistinct cell membranes. Neoplastic cells the basement membrane to the last cell of the invasion focus. (C)
are limited by the intact eosinophilic basement membrane , Invasion is measured from the site of origin to the last cell of the
leading to the term "preinvasive carcinoma." invasion focus.
T1a1 T1a1
Low-power magnification H&E of the cervix shows there is loss of Higher power magnification shows the invasive squamous nests
squamous epithelium on the right with underlying moderately with mitotic figures and prominent surrounding inflammatory
differentiated carcinoma characterized by irregular nests of infiltrate.
squamous cells invading the stroma. Nests extend to a depth of
1.5 mm from the basement membrane .
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CERVICAL CARCINOMA
Cervix
T1a2 T1b1
H&E section of the cervix with stromal depth of invasion of 3.5 mm H&E stain shows invasive squamous cell carcinoma with a
is characteristic of tumor stage T1a2. microscopic depth of invasion of 6 mm. Clinically, this lesion
was visible; however, it was confined to the cervix and < 4 cm in
greatest dimension.
T3 T3
Low-power magnification of H&E-stained slide shows cervical Higher power magnification shows uninvolved nonkeratinized
squamous cell carcinoma involving the lower 1/3 of the vagina. vaginal surface epithelium with subepithelial cords and nests of
neoplastic cells .
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T1a1 T1a2
Stage T1a1 cervical carcinoma is defined as a microscopic Stage T1a2 cervical carcinoma is a microscopic tumor with stromal
tumor with stromal invasion of ≤ 3 mm in depth and ≤ 7 mm in invasion of 4-5 mm in depth and ≤ 7 mm in horizontal spread.
horizontal spread.
T1b1 T1b2
Stage T1b1 cervical carcinoma is a microscopic or clinically visible Stage T1b2 cervical carcinoma is a clinically visible lesion > 4 cm
lesion. Microscopic tumors have stromal invasion > 5 mm in depth in size. Tumors at this stage are confined to the cervix. Tumors may
or > 7 mm in horizontal spread. Clinically visible tumors are ≤ 4 cm be exophytic, extending into the vaginal vault; however, there is no
in size. All lesions at this stage are confined to the cervix. invasion of adjacent structures.
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CERVICAL CARCINOMA
Cervix
T2a1 and T2a2 T2b
Stage T2a tumors extend beyond the cervix to invade the upper 2/3 Stage T2b tumors extend beyond the cervix to invade the
of the vagina. Graphics are sagittal views of the pelvis showing the parametrium. Graphic looks into the pelvic bowl and depicts
tumor invading the upper vagina. Left graphic depicts stage T2a1 tumors invading the parametrium, including fat, uterine ligaments,
with the tumor ≤ 4 cm in size. Right graphic depicts stage T2a2 and paracervical vessels.
with the tumor > 4 cm in size.
T2b T3a
Stage T2b tumors extend beyond the cervix to invade the Stage T3a tumors invade the lower 1/3 of the vagina. Graphic is
parametrium. Graphic is a view in the coronal plane depicting the a sagittal view of the pelvis showing the tumor invading the lower
tumor invading the parametrium, including fat, uterine ligaments, vagina.
and paracervical vessels. There is encasement of the ureter;
however, no hydronephrosis is present.
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T3b T3b
Stage T3b tumors extend to the pelvic sidewall &/or cause Stage T3b tumors extend to the pelvic sidewall &/or cause
hydronephrosis. Graphics are views into the pelvic bowl. The left hydronephrosis. Graphic is a view in the coronal plane showing the
graphic depicts the tumor extending to the pelvic sidewall to encase tumor extending to the pelvic sidewall to encase the external iliac
the iliac vessels and invade the musculature. The right graphic vessels and invade the musculature. The tumor invades the ureter,
depicts the tumor invading the ureter, resulting in hydronephrosis. causing hydronephrosis (not shown).
T4 T4
Stage T4 tumors invade the urinary bladder or rectal mucosa. Stage T4 tumors invade the urinary bladder or rectal mucosa.
Graphic looks into the pelvic bowl and shows tumors invading Graphic is a sagittal view of the pelvis showing the tumor invading
the urinary bladder mucosa anteriorly and the rectal mucosa the urinary bladder mucosa anteriorly and the rectal mucosa
posteriorly. posteriorly.
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CERVICAL CARCINOMA
Cervix
N1 N1
Frontal view of the female pelvis depicts lymph node chains. Lateral view of the pelvis shows the presacral and hypogastric
Regional lymph nodes in cervical carcinoma are highlighted and routes of lymphatic drainage more clearly. The obturator lymph
include parametrial, obturator, internal iliac, external iliac, common node, often the sentinel node in cervical carcinoma, is also shown.
iliac, sacral, and presacral lymph nodes.

Liver 33%
Lung 33-38%
Bone 15-29%
Adrenal gland 15%
Paraaortic lymph nodes 15%
Supraclavicular nodes 7%
Abdominal cavity 5-27%
Reported organ frequency of metastatic disease is based on

findings at autopsy in patients with recurrent cervical cancer.
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– Junctional lymph nodes lie between internal and

OVERVIEW external iliac vessels
▪ Presacral route
General Comments – Along uterosacral ligament
• 3rd most common gynecologic malignancy – Uterosacral ligament → lymphatic plexus
• 70% are squamous cell carcinoma
anterior to sacrum
Classification o All 3 routes of lymphatic drainage of cervix drain to
• Histopathologic types common iliac chains
o Cervical intraepithelial neoplasia (CIN), grade III o Common iliac chains drain to paraaortic lymph
o Squamous cell carcinoma in situ nodes
o Squamous cell carcinoma o Depth of invasion of cervix and adjacent structures
▪ Invasive may affect nodal involvement
▪ Keratinizing ▪ Parametrial and pelvic sidewall invasion
▪ Nonkeratinizing – Drainage by external iliac lymph nodes
▪ Verrucous ▪ Invasion of lower 1/3 of vagina
o Adenocarcinoma in situ – Drainage by inguinal lymph nodes
o Invasive adenocarcinoma ▪ Rectal wall invasion
o Endometrioid adenocarcinoma – Drainage by inferior mesenteric lymph nodes
o Clear cell adenocarcinoma • Peritoneal seeding
o Adenosquamous carcinoma o Peritoneal metastasis varies from 5-27% in autopsy
o Adenoid cystic carcinoma series
o Adenoid basal cell carcinoma o Mesenteric or omental metastases are uncommon
o Small cell carcinoma o "Sister Joseph" nodule
o Neuroendocrine ▪ Umbilical metastasis
o Undifferentiated carcinoma ▪ Direct extension of tumor from anterior peritoneal
surface
• Hematogenous spread
PATHOLOGY o Liver is most common abdominal organ with
metastases
Routes of Spread o Adrenal gland is 2nd most common metastatic site in
• Contiguous spread abdomen
o Most common mode of spread o Pulmonary metastases are relatively common in
o Caudally to invade autopsy series (33-38%)
▪ Vagina ▪ May be present for significant period of time;
o Anteriorly to invade however, may remain asymptomatic
▪ Vesicouterine ligament ▪ 1/3 will have mediastinal or hilar adenopathy
▪ Urinary bladder ▪ Lymphangitic carcinomatosis occurs in < 5%
o Laterally to invade
▪ Cardinal ligaments
General Features
▪ Paracervical tissues
• Comments
o Cervical cancer originates at squamocolumnar
– Fat, vessels, ureters, lymphatics
junction (SCJ)
▪ Pelvic sidewall in advanced disease
▪ SCJ is originally located in ectocervix (intravaginal)
– Iliac vessels, pelvic musculature
o Posteriorly to invade ▪ SCJ moves to endocervix with advancing age
▪ Cancer arises in transformation zone between old
▪ Uterosacral ligaments
and new SCJ
▪ Rectum o Migration of SCJ accounts for age-related change in
• Lymphatic spread
o Significant prognostic indicator tumor growth pattern
o ↑ incidence with advancing stage of disease ▪ Young women: Exophytic growth
o Correlates with ↓ disease-free survival ▪ Older women: Endophytic growth
o Squamous cell carcinoma
o ↑ incidence of recurrence at each stage with
▪ Most common histologic subtype, accounting for
lymphatic invasion 70%
o Lymphatic drainage of cervix o Adenocarcinoma
▪ Parametrial → obturator → internal/external iliac ▪ 2nd most common, accounting for 25%
o 3 pathways of lymphatic drainage of cervix
▪ Significant increase in incidence over last several
▪ Lateral route decades
– Parallels external iliac vessels ▪ Aggressive subtype
– Tumor drains 1st to medial external iliac chain, ▪ More often advanced at presentation
then to middle and lateral chains o Small cell carcinoma
– Deep inguinal lymph drain via lateral route ▪ Accounts for 2% of cervical cancers
▪ Hypogastric route ▪ Pap smear not sensitive for diagnosis of this
– Parallels internal iliac vessels subtype
– Lymph nodes along internal iliac branches drain
3 to junctional lymph nodes
– Accuracy of 14% in 1 study
▪ Aggressive biologic behavior
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Cervix
▪ Higher incidence of lymph node metastases, – Sheets and nests of malignant squamous cells
parametrial invasion, and systemic metastases even invade stroma
with small tumors – Abundant cytoplasm
▪ Nonspecific imaging appearance – Large pleomorphic nuclei and inconspicuous
o Adenoma malignum nucleoli
▪ Subtype of adenocarcinoma (3%) – Keratin pearls and intercellular bridges
▪ Arises from columnar epithelium of endocervical – Occasional mitotic figures
canal – Infiltrative growth pattern
▪ Composed of well-differentiated endocervical ▪ Large cell nonkeratinizing squamous cell
glands carcinoma
▪ History of copious watery discharge – Large cells of similar size and shape
▪ Prognosis is poor – Moderate cytoplasm
– Early peritoneal metastases – May have individual cell keratinization
– Poor response to chemoradiation therapy – Keratin pearls are absent
▪ Associated with Peutz-Jeghers syndrome – Prominent nucleoli
o Clear cell adenocarcinoma – Mitotic figures are common
▪ Rare histologic subtype of adenocarcinoma – Invasive edge is smooth
▪ Associated with in utero diethylstilbestrol (DES) ▪ Small cell nonkeratinizing (poorly differentiated)
exposure – Nests, cords, sheets ± single cells
▪ Case reports suggest possible association with – May have focal keratinization
cervical endometriosis – Small cells with hyperchromatic nuclei
• Etiology ▪ Desmoplastic stromal response
o Risk factors for cervical cancer ▪ ± lymphovascular invasion
▪ High-risk strains of human papilloma virus (HPV) ▪ May see focal mucinous differentiation
▪ Sexual activity at early age ▪ Depth of invasion = most superficial epithelial-
▪ Multiple sexual partners stromal to deepest
▪ Sexually transmitted disease ▪ Morphologic variants
▪ Multiparity – Spindled: Nests of well to moderately
▪ Low socioeconomic status differentiated carcinoma transitioning to
▪ Cigarette smoking spindled cells with hyperchromatic nuclei &
▪ Immunosuppression prominent nucleoli, numerous mitoses, few
▪ Long-term use of oral contraceptives osteoclast-like giant cells
▪ In utero DES exposure – Lymphoepithelial-like carcinoma: Nests of
– Clear cell adenocarcinoma dyscohesive squamous cells with vesicular
o 70% of cervical cancer is caused by HPV-16 and -18 nuclei and nucleoli, indistinct cell borders
o 27% of women in USA age 14-59 years are positive for with prominent lymphocytic infiltrate, no
at least 1 strain of HPV keritanization
▪ 15.2% are positive for 1 of high-risk strains – Verrucous carcinoma: Exophytic growth with
o Women with HIV/AIDS have poor prognosis, often acanthotic squamous epithelium, hyperkeratosis
rapidly progressive cancer and parakeratosis, broad-based invasion,
• Epidemiology & cancer incidence minimal cytologic atypia, rare mitoses
o 3rd most common gynecologic malignancy – Condylomatous (warty) carcinoma: Exophytic,
following endometrial and ovarian cancer frond-like acanthotic squamous epithelium,
o Decreased incidence since introduction and well-differentiated polygonal cells with
widespread use of Papanicolaou smear conspicuous atypia of basal layer and superficial
o Estimated 12,340 women will be diagnosed in 2013 koilocytotic atypia
in USA – Papillary squamous and squamotransitional
o Estimated 4,030 cervical cancer-related deaths in carcinoma: Papillae with fibrovascular
2013 in USA cores lined by multilayered epithelium
with variable squamous &/or transitional
Gross Pathology & Surgical Features differentiation, abundant eosinophilic
• Gross appearance cytoplasm, hyperchromatic nuclei with nucleoli
o Poorly circumscribed granular or eroded appearance
– Basaloid squamous carcinoma: Small nests of
o Nodular, ulcerated lesion or exophytic mass
basaloid cells with peripheral palisading of
o Diffuse enlargement and hardening of cervix
nuclei, may see cords and single cells, occasional
▪ Endophytic infiltrative lesion in cervical canal
keratinization, scant cytoplasm, hyperchromatic
o Barrel-shaped cervix
nuclei, frequent mitoses
▪ Diffusely enlarged, bulky, and > 6 cm o Adenocarcinoma
▪ Most common with adenocarcinoma ▪ Usually moderately differentiated
Microscopic Pathology – Closely packed or irregularly spaced glands
• H&E – Cribriform, microglandular, papillary, cystic or
o Squamous cell carcinoma solid growth
▪ Large-cell keratinizing squamous cell carcinoma ▪ Poorly differentiated
– Clusters, cords, or single cells
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▪ ± desmoplastic stroma/inflammatory reaction – At most, mild cytologic atypia

▪ Occasional mucin pools – Round to oval nuclei
▪ ± lymphovascular invasion – Inconspicuous nucleoli
▪ Hyperchromatic nuclei – "Salt and pepper" chromatin
– Enlarged and crowded – Rare mitoses
▪ Frequently have apical mitoses and apoptotic ▪ Atypical carcinoid
bodies – Organoid nested pattern most common
▪ 60% are associated with squamous intraepithelial – Trabecular, insular, ribbon- and follicle-like
lesion or carcinoma patterns
o Villoglandular adenocarcinoma – Rosette-like structures
▪ Papillary architecture (tall and thin papillae lined – Foci of necrosis
by stratified epithelium) – Mild to moderate cytologic atypia
▪ Fibrovascular core with inflammatory cells – "Salt and pepper" chromatin
▪ Absent or minimal superficial invasion, rare deep – 5-10 mitoses/10 HPF
invasion ▪ Small cell neuroendocrine carcinoma
▪ Often associated with squamous intraepithelial – Most frequent subtype
neoplasia &/or adenocarcinoma in situ – Diffuse, insular, corded, trabecular, or nested
▪ Low-grade nuclear features growth
▪ Low mitotic rate – Occasionally rosette-like or acinar formations
▪ CEA and p16 positive – Squamous/glandular differentiation may be
o Endometrioid adenocarcinoma present
▪ Most commonly simple tubular glands – Typically hypercellular
▪ Complex glandular architecture with cribriform – Prominent necrosis and lymphovascular
and papillary patterns invasion
▪ Pseudostratified columnar cells with round nuclei – Nonneuroendocrine or in situ adenocarcinoma
▪ Cytoplasm with little or no mucin may be seen
▪ Ciliated cells but no squamous metaplasia – Infrequently, in situ or invasive squamous cell
▪ Often have adjacent adenocarcinoma in situ carcinoma may be seen
▪ CEA and p16 positive – Small, round, oval to spindle cells with increased
▪ ER, PR, and vimentin negative nuclear:cytoplasmic ratio
o Clear cell adenocarcinoma – "Salt and pepper" chromatin
▪ Solid (sheets), tubular, cystic, and (less commonly) – > 10 mitoses/10 HPF
papillary growths – Numerous apoptotic bodies
▪ Tubules and cysts with intraluminal eosinophilic/ ▪ Large cell neuroendocrine carcinoma
mucinous secretions (PAS-D and mucin positive) – Diffuse, insular, or trabecular
▪ Flat to cuboidal cells; variable number of hobnail – Prominent peripheral palisading
cells – Focal glandular differentiation
▪ Often clear and less commonly eosinophilic – Geographic necrosis and lymphovascular
cytoplasm invasion
▪ Can be associated with endometriosis – Frequently associated with nonneuroendocrine
▪ Hepatocyte nuclear factor positive invasive or in situ adenocarcinoma &/or
▪ p16 often positive; HPV negative squamous cell carcinoma
o Adenoid basal carcinoma – Occasionally mixed with small component of
▪ Resembles basal cell carcinoma of skin small cell neuroendocrine carcinoma
▪ Small nests with peripheral palisading – Medium to large cells
▪ Bland cytology – Abundant eosinophilic/argyrophilic cytoplasm
▪ Few to absent mitoses – High-grade nuclei with prominent nucleoli
▪ No stromal response – ± peripheral palisading
▪ Associated with high-grade squamous – > 10 mitoses/10 HPF
intraepithelial lesion o Histologic grade
o Adenoid cystic carcinoma ▪ Degree of differentiation of tumor cells
▪ Cribriform spaces with eosinophilic hyaline to ▪ Based on amount of keratin, degree of nuclear
mucinous basement membrane-like material atypia, mitotic activity
▪ Stromal myxoid, fibroblastic, or hyaline response ▪ Correlates with frequency of pelvic nodal
▪ Moderately pleomorphic nuclei and high mitotic metastasis
rate ▪ Grade 1: Well differentiated
o Neuroendocrine tumors – Abundant intercellular bridging
▪ Carcinoid – Cytoplasmic keratinization
– Organoid nested growth most common – Keratin pearls
– Trabecular, insular, ribbon- and follicle-like – Cells are uniform with minimal nuclear
patterns pleomorphism
– Rosette-like structures (perivascular are – Mitotic rate is < 2 mitoses/HPF
common) ▪ Grade 2: Moderately differentiated
3 – No necrosis – Individual cell keratinization
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CERVICAL CARCINOMA
Cervix
– Moderate nuclear pleomorphism – Paracervical ligaments and vessels may be
– Mitotic rate is ≤ 4 mitoses/HPF mistaken for soft tissue strands
▪ Grade 3: Poorly differentiated • MR
– Minimal evidence of squamous differentiation o Ideal for local cervical cancer staging
– Cells are immature with marked nuclear ▪ Superior soft tissue contrast
pleomorphism and scant cytoplasm ▪ Multiplanar capability
– Mitotic rate is > 4 mitoses/HPF o Superior to clinical evaluation and other imaging
• Immunohistochemistry modalities with regard to tumor characteristics that
o Squamous cell carcinoma determine prognosis and stage
▪ CK7, p63, p16 positive ▪ Tumor size
o Adenocarcinoma ▪ Parametrial invasion
▪ p16, ProEx C, CEA positive ▪ Vaginal wall invasion
▪ Vimentin, ER, PR negative ▪ Pelvic sidewall extension
o Neuroendocrine tumors o Accuracy is 94% in selecting operative candidates
▪ Low molecular weight cytokeratin (punctate ▪ Compared with 76% for CT
staining) o Including MR in pretreatment work-up significantly
– Variably positive EMA, CEA, p16, p53 decreases number of procedures and invasive studies
▪ Neuroendocrine markers often positive o Typical MR findings of cervical cancer
– Synaptophysin, chromogranin, NSE, CD56, ▪ T2 hyperintense mass disrupting normal
LEU-7 hypointense cervical stroma
▪ TTF-1 positive in up to 40% ▪ Endophytic: Arises from endocervical canal
▪ Polypeptide and amine hormones are occasionally ▪ Exophytic: Arises from ectocervix and extends into
positive vaginal vault
– Somatostatin, serotonin, calcitonin, insulin, o MR technique
glucagon ▪ T2WI best for visualization of tumor and local
• PCR staging
o Adenocarcinoma – FSE, small field of view (FOV), high resolution
▪ High-risk HPV strain positive ▪ Coronal oblique T2WI: Long and short (donut
o Neuroendocrine tumors view) axis of cervix
▪ HPV positive (type 16 or 18) – Evaluation of depth of cervical stromal invasion
– Evaluation of parametrial invasion
▪ Sagittal T2WI
IMAGING FINDINGS – Depth of cervical stromal invasion
– Visualization of invasion of vagina and urinary
Detection bladder
• Ultrasound – Helpful to distend vagina with gel
o Inadequate for diagnosis, staging, and surveillance ▪ Axial T2WI
for recurrence – Parametrial invasion
o Technically limited by body habitus, low signal:noise – Pelvic sidewall invasion
ratio, and lack of tissue characterization – Rectal invasion
• CT ▪ T2WI with fat saturation
o 92% accuracy for stage IIIB-IVB disease – Helpful if prominent paracervical venous plexus
o Can demonstrate ▪ IV contrast reportedly not helpful for depth of
▪ Pelvic sidewall extension stromal invasion or parametrial involvement
▪ Ureteral obstruction – Loss of soft tissue contrast due to enhancement
▪ Advanced bladder and rectal invasion of normal cervical stroma and variable tumor
▪ Adenopathy enhancement
▪ Extrapelvic spread of disease – May result in overestimation of tumor size
o May see distension of uterine cavity with fluid/blood ▪ IV contrast is useful in advanced disease to evaluate
if tumor obstructs endocervical canal – Rectal, urinary bladder, pelvic sidewall invasion
o Can guide lymph node biopsy and radiation – Pelvic fistulas
planning – Recurrent/residual disease post radiation or
o Has high sensitivity and specificity for detection of surgery
recurrent tumor ▪ Diffusion weighted imaging (DWI)
▪ Soft tissue mass with variable degrees of necrosis – Utility of DWI is under investigation
▪ Cystic mass with minimal soft tissue – Mean ADC value of cervical carcinoma has been
o Limitations found to be significantly lower than normal
▪ Limited visualization of primary tumor cervix
– Hypodense/isodense to normal cervical stroma – May be helpful for delineation of tumor margins
– Tumor detection and depth of invasion difficult of otherwise isointense tumors and early cervical
▪ Inaccurate for detection of parametrial invasion cancer
– 30-58% accuracy – May be useful as biomarker of response to
– Parametrial inflammation can mimic treatment
parametrial tumor infiltration
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– Increase in ADC value of tumor has been found ▪ Cystoscopy and proctoscopy
as early as after 2 weeks of therapy (before ▪ Aforementioned radiologic and endoscopic studies
change in tumor size) and was indicative of are often not used in clinical practice
treatment response o MR is more accurate for staging compared to clinical
o Limitations of MR FIGO staging
▪ Differentiating tumor recurrence from early ▪ Particularly in patients with ≥ stage IIA disease
radiation change and infection • Stage IA
▪ May overestimate parametrial invasion with large o Microinvasive disease
tumors o Traditionally not visible on MR
– Due to surrounding stromal edema from tumor o Some reports describe area of enhancement in
compression or inflammation arterial phase on dynamic post-contrast imaging
• PET/CT • Stage IB
o Excellent for detection of lymphadenopathy and o Clinically visible (> 5 mm); however, tumor remains
distant metastatic disease confined to cervix
▪ 100% sensitivity and 99.6% specificity for lymph o Hyperintense mass disrupting low-signal cervical
nodes > 5 mm in short axis stroma on T2WI
▪ 100% sensitivity and 94% specificity for distant o Partial stromal invasion
metastatic disease ▪ Preservation of outer rim of normal low signal
o Superior to MR and CT for depiction of adenopathy cervical stroma on T2WI
▪ Metabolic changes may precede morphologic ▪ Parametrial invasion can reliably be excluded if rim
changes of normal stroma is ≥ 3 mm
▪ Moderate to marked increase FDG uptake relative o Full thickness stromal invasion
to normal structures ▪ No outer rim of normal cervical stroma
▪ SUV is not helpful when characterizing lymph ▪ Parametrial tissue is symmetric and normal in
node lesions signal intensity
o Can be used to assess treatment response 3 months ▪ Preservation of sharp, distinct parametrial fat
after completion of chemoradiation planes
o Limitations ▪ Excluding parametrial invasion is more difficult
▪ Lower spatial resolution compared to CT and MR with full thickness invasion
▪ Cannot resolve micrometastases ▪ If vaginal fornices are not invaded, tumor is likely
▪ Cannot differentiate malignant from reactive confined to cervix
adenopathy o Exophytic cervical mass can fill and expand vaginal
▪ Cannot differentiate malignant, infectious, or fornices
inflammatory processes ▪ If low signal vaginal wall is preserved (no invasion),
o Poor anatomic resolution of PET is overcome by this remains stage IB tumor
fusion with CT • Stage IIA
o Invasion of upper 2/3 of vagina
Staging o Disruption of normal low signal vaginal wall by
• General comments hyperintense cervical mass on T2WI
o Accurate staging is critical for guiding management
o Important to avoid upstaging at time of surgery
• Stage IIB
o Invasion of parametrial tissues
▪ Significant increase in morbidity when surgery and ▪ Vessels, fat, and lymphatics between leaves of
radiotherapy are combined broad ligament
o International Federation of Gynecology and o Probability of parametrial invasion is 28% for tumors
Obstetrics (FIGO) > 2 cm
▪ Clinical staging of cervical cancer o Specific signs of parametrial invasion
▪ Preferred staging system in order to provide ▪ Frank extension of mass into parametrial tissues
uniformity ▪ Encasement of parametrial vessels
▪ Results of imaging technologies (CT, MR, PET) ▪ Encasement of ureter (no hydronephrosis)
should not be used to determine clinical stage ▪ Nodular thickening of uterine ligaments
– Not universally available o Early parametrial invasion may manifest as
– Can be used for prognostic information and ▪ Full thickness cervical stromal invasion by tumor
treatment planning with irregularity of outer cervical contour
▪ Surgical and pathologic findings should not ▪ Stranding (> 3-4 mm in thickness) and nodularity
change clinical stage of parametrial fat
– Can be used in TNM staging – These findings are nonspecific and can be
▪ Clinical stage must not be changed for subsequent
secondary to parametrial inflammation
findings once treatment is started o Coronal oblique (donut) and sagittal T2WI are best
▪ If there is doubt regarding stage, lesser stage should
for identifying parametrial involvement
be used o T2WI with fat saturation may be helpful in women
o FIGO staging system is based on
with prominent paracervical venous plexus
▪ Clinical examination (under anesthesia) • Stage IIIA
▪ Chest x-ray o Invasion of lower 1/3 of vagina
▪ Intravenous pyelogram
3 ▪ Barium enema
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CERVICAL CARCINOMA
Cervix
o Disruption of normal low-signal vaginal wall by ▪ Overall incidence: 56%
hyperintense cervical mass on T2WI ▪ 10% have metastatic disease at time of diagnosis
o Best evaluated in axial and sagittal planes o Factors influencing incidence of distant metastasis
• Stage IIIB ▪ Clinical stage at diagnosis
o Hydronephrosis or pelvic sidewall invasion ▪ Endometrial extension as shown at pretreatment
▪ Pelvic sidewall invasion manifests as dilation and curettage
– Tumor extension to within 3 mm of pelvic ▪ Pelvic tumor control with treatment
musculature o Incidence of distant metastases increases with
– Invasion of obturator internus and piriformis increasing stage of disease
muscles: Diffuse enlargement or mass ▪ Stage IA (3%) → stage IVA (75%)
– Encasement of iliac vessels by tumor o Most common organs
▪ Ureteral invasion as manifested by hydronephrosis ▪ Liver, lungs, abdominal cavity, and GI tract
can be identified with US, CT, or MR o Most common lymph nodes
▪ Enlarge FOV on coronal fluid-sensitive sequence to ▪ Paraaortic, supraclavicular, and inguinal
evaluate entire urinary tract ▪ Low sensitivity/specificity of CT and MR for
o Any T stage with regional nodal metastases detection of metastatic adenopathy
▪ Lymph node metastases are detected equally well ▪ PET/CT overall sensitivity/specificity for paraaortic
with CT and MR adenopathy: 36/96%
▪ CT and MR are slightly better than ▪ PET/CT sensitivity/specificity in subset with
lymphangiography positive pelvic lymph nodes: 45/91%
▪ Anatomic imaging uses lymph node size and shape o Most common bones
to predict presence of pathology ▪ Thoracic and lumbar spine
– Spherical shape ▪ Destructive lesions
– Size > 1 cm in short axis: 75-88% accuracy ▪ Usually by contiguous extension from paraaortic
– Approximately 50% of metastatic lymph nodes lymph node mass
have been found to be < 1 cm ▪ Pelvis, ribs, and extremities less frequently
▪ IV contrast aids in detection of lymph nodes involved
– Lymph nodes avidly enhance o Liver is most common abdominal organ with
– ↑ conspicuity in hypodense pelvic fat on CT or metastases
low signal pelvic fat on T1WI C+ FS MR ▪ Solid mass with variable enhancement on CECT or
▪ DWI with ADC calculation is a promising MR
technique for detection of metastatic adenopathy ▪ Increased FDG activity compared with background
▪ Central necrosis is highly predictive of metastasis liver on PET/CT
– Lack of central enhancement o Peritoneal carcinomatosis
▪ Metabolic imaging with PET utilizes presence of ▪ Implants scalloping liver contour
increased glucose metabolism to predict pathology ▪ Irregular and nodular peritoneal thickening
– Relative increased FDG uptake compared to ▪ Mass or infiltrative soft tissue in mesentery or
other lymph nodes is considered positive omentum
▪ Detection of micrometastases remains a challenge ▪ Soft tissue masses on serosal surface of bowel
for both anatomic and metabolic imaging ▪ Ascites is often present, though nonspecific
▪ Reactive adenopathy can be difficult to o Pleural involvement
differentiate from malignant adenopathy ▪ Pleural thickening and nodularity
• Stage IVA ▪ Hydrothorax (often seen with ascites)
o Invasion of urinary bladder or rectal mucosa ▪ More common with adenocarcinoma
o Disruption of normal low signal urinary bladder or o Pericardial metastasis is rare
rectal wall by high signal tumor on T2WI ▪ Nodular pericardial thickening
o Eccentric nodular wall thickening ▪ Pericardial effusion
o Protrusion of tumor into lumen ▪ Spread via paraaortic lymph nodes
o Fistula formation: Tumor to urinary bladder or o Rare metastatic sites
rectum ▪ Skin, brain, meninges, heart, and breast
▪ Enhancing tract on post-contrast sequences ▪ Usually occur in recurrent cervical cancer
▪ Intraluminal air in urinary bladder
o Bullous edema sign Restaging
▪ High signal thickening of urinary bladder wall on • Recurrence is defined as development of tumor ≥ 6
T2WI months following disease regression
▪ Reactive inflammation, not tumor invasion • Up to 20% of cases of cervical cancer recur
▪ Not stage IVA if occurring in isolation • Most important predictor of disease recurrence is
o Bladder and rectal mucosal involvement must be paraaortic nodal status
confirmed by biopsy and histology • Risk factors for recurrence
• Stage IVB o Histologic grade
o Distant metastatic disease including extrapelvic o Tumor size
lymph nodes o Depth of stromal invasion
o Metastatic disease is most commonly seen with o Lymph node status at presentation
• Most common sites of local recurrence
recurrence or advanced disease
o Cervix 3
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o Vaginal cuff
o Parametrial tissues Treatment Options
o Pelvic sidewall • Major treatment alternatives
o Surgical resection
• Local recurrence in pelvis
o Central ▪ Trachelectomy
▪ At remaining cervix or vaginal cuff – Maintains fertility
▪ Can extend anteriorly to ureter or bladder – Depends on relationship of tumor to internal os
▪ Posteriorly to invade rectum ▪ Wertheim-Meigs operation
– ± rectovaginal fistula – Total abdominal hysterectomy
▪ Laterally to pelvic sidewall – Resection of upper 1/3 of vagina
o Pelvic sidewall – Excision of parametrial and uterosacral
▪ Invasion precludes treatment with pelvic ligaments
exenteration – Pelvic and periaortic lymph node dissection
o Radiation therapy
• CT
o Overall high sensitivity and specificity in detection of ▪ External beam pelvic radiation and intracavitary
recurrent tumor brachytherapy
o Limited ability to differentiate early radiation ▪ Can extend radiation field to include paraaortic
change/fibrosis from recurrence lymph nodes
o Readily available – Long-term disease control if low volume (< 2 cm)
o Short scan time eliminates bowel motion artifact nodal disease below L3
o Chemotherapy
• MR
o Contrast-enhanced MR: Accuracy of 82% for ▪ Survival advantage in stage IB2-IVA disease when
distinguishing recurrence from fibrosis concurrent with radiation therapy
o Can assess extent of vaginal and pelvic floor ▪ Advantageous in stage I-IIA disease if found to have
involvement poor prognostic factors at surgery
o Disadvantages include cost and long scan time ▪ Risk of death is decreased by 30-50%
• PET/CT • Stage 0
o Able to differentiate metabolically active tumor from o Absence of invasion must be confirmed with
therapy-related fibrosis colposcopic-directed biopsy or cone biopsy
o Whole-body evaluation for distant metastases o Loop electrosurgical excision procedure (LEEP)
o Poor spatial resolution precludes evaluation of local ▪ Outpatient, in-office procedure
tumor invasion of adjacent structures ▪ Requires only local anesthesia
o Laser or cold-knife conization
▪ Preserves uterus
▪ Avoids radiation therapy and surgery
CLINICAL ISSUES ▪ Requires general anesthesia
Presentation ▪ Mandatory if
• Average age of presentation: 50 years – Extension of disease into endocervical canal
o 2 peaks at age 38 and 62 years – Lack of correlation between cytology and
• Most common symptoms are vaginal bleeding and colposcopic-directed biopsy
discharge – Adenocarcinoma in situ
o Most common cause of failure at this stage is
• CIN is precursor to cervical cancer
o CIN 1: Minor dysplasia unrecognized invasive disease treated with
o CIN 2: Moderate dysplasia inadequate ablative therapy
o CIN 3: Severe dysplasia • Stage IA
o Total hysterectomy
▪ 40% progress to invasive cancer if not treated
▪ Average time to progression: 10-15 years ▪ Depth of tumor invasion < 3 mm (proven by cone
• Paraneoplastic manifestations with neuroendocrine biopsy)
tumors ▪ Negative cone biopsy margins
o Cushing syndrome (ACTH) ▪ No vascular or lymphatic channel invasion
o Syndrome of inappropriate diuretic hormone o Conization
(SIADH) ▪ Depth of tumor invasion < 3 mm (proven by cone
o Carcinoid syndrome (serotonin) biopsy)
o Hypoglycemia (insulin) ▪ Negative cone biopsy margins
▪ No vascular or lymphatic channel invasion
Cancer Natural History & Prognosis ▪ Considered if desire to preserve fertility
• Major factors influencing prognosis o Radical hysterectomy (including pelvic lymph node
o Histologic type and grade dissection)
o Stage ▪ Depth of tumor invasion 3-5 mm or unknown due
o Tumor volume to positive cone margins
o Depth of stromal invasion ▪ Lymph node dissection done due to reported risk
o Adjacent tissue extension of lymph node metastasis of up to 10%
o Lymphatic spread o Intracavitary radiation therapy
o ▪ Reserved for women who are not surgical
3 Vascular invasion
candidates
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CERVICAL CARCINOMA
Cervix
▪ Depth of tumor invasion < 3 mm
▪ No lymphatic or vascular space invasion REPORTING CHECKLIST
• Stage IB/IIA T Staging
o Identical overall and 5-year disease-free survival rates
for radiation therapy and radical hysterectomy
• Size
▪ Stage IB
• Endophytic vs. exophytic mass
– 85-90% cure rate (small- volume disease)
• Obstruction of endocervical canal
o Distension of uterine cavity
▪ Stage IIA
– 75-80% cure rate
• Contiguous spread
o Vagina
o Radiation therapy
▪ Upper 2/3
▪ External beam pelvic radiation combined with
▪ Lower 1/3
intracavitary brachytherapy o Parametrial invasion
▪ May also be beneficial in those with close vaginal
▪ Loss of outer rim of normal cervical stroma
margins (< 0.5 cm) at radical surgery
▪ Frank tumor extension
▪ Extended field radiation
▪ Encasement of pericervical vessels
– May be used to control small-volume paraaortic
▪ Soft tissue nodules and strands (> 3 mm)
nodal disease
▪ Uterosacral, cardinal, vesicouterine ligaments
– Possible survival advantage with large tumors
– Nodular thickening
even without histologic evidence of paraaortic o Pelvic sidewall
metastases
▪ Common, internal, and external iliac artery and
– ↑ toxic effects if history of prior abdominopelvic
vein
surgery
o Radical hysterectomy and bilateral pelvic lymph – Vessel encasement
▪ Pelvic musculature
node dissection
– Obturator internus, piriformis, psoas, iliacus
▪ Surgery indicated after radiation therapy if
– Tumor within 3 mm of muscle
– Tumor is confined to cervix but responds
– Diffuse muscle enlargement or mass
incompletely to radiation therapy o Ureteral invasion
– Vaginal anatomy precludes optimal
▪ Hydronephrosis
brachytherapy o Urinary bladder and rectal mucosa
o Radical hysterectomy, lymph node dissection,
▪ Eccentric nodular wall thickening
radiation therapy, and chemotherapy
▪ Protrusion of tumor into lumen
▪ Considered if
▪ Fistula from tumor to bladder or rectum
– Positive pelvic lymph nodes
– Enhancing tract
– Positive surgical margins
– Intraluminal air in urinary bladder
– Residual parametrial disease
o Radiation and chemotherapy ▪ Bullous edema sign
– Reactive inflammation, not tumor invasion
▪ Considered for bulky tumors
▪ Studies have shown overall survival advantage with N Staging
concurrent chemoradiation therapy • Pelvic lymph nodes
• Stage IIB/III/IVA o Obturator
o Stage IIB o Internal, external, and common iliac
▪ Survival and local control are better with unilateral o Presacral
parametrial involvement vs. bilateral • Anatomic imaging
o Stage III o Size > 1 cm in short axis
▪ Better survival outcome with unilateral pelvic o Spherical shape
sidewall involvement vs. bilateral o Central necrosis
▪ Lower 1/3 vaginal invasion has worse survival • Metabolic imaging
outcome than pelvic wall disease o Relative increased FDG uptake
o Radiation and chemotherapy
▪ External beam pelvic radiation combined with M Staging
intracavitary brachytherapy • Hematogenous metastasis
▪ ↓ risk of death by 30-50% with use of concurrent o Liver, adrenal gland, lung
chemotherapy • Extrapelvic lymph nodes
▪ Resection of macroscopically involved pelvic o Paraaortic, inguinal, supraclavicular most common
nodes may improve rates of local control with • Peritoneal metastasis
postoperative radiation therapy o Implants scalloping liver contour
• Stage IVB o Irregular and nodular peritoneal thickening
o Radiation therapy may be used to palliate central o Soft tissue masses on serosal surface of bowel
disease or distant metastasis o Omental or mesenteric mass
o No standard chemotherapy treatment is available o Ascites
o Clinical trials using single or multiple agents are • Osseous metastasis
ongoing o Thoracic and lumbar spine most common
▪ Contiguous extension from paraaortic mass
o Pelvis, ribs, extremities less common
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24. Metser U et al: MR imaging findings and patterns of spread

SELECTED REFERENCES in secondary tumor involvement of the uterine body and
1. American Cancer Society. What are the key statistics cervix. AJR Am J Roentgenol. 180(3):765-9, 2003
about cervical cancer? http://www.cancer.org/cancer/ 25. Okamoto Y et al: MR imaging of the uterine cervix: imaging-
cervicalcancer/detailedguide/cervical-cancer-key-statistics. pathologic correlation. Radiographics. 23(2):425-45; quiz
Accessed January 30, 2014 534-5, 2003
2. Fu Y: Pathology of cervical carcinoma. Global Library of 26. Scheidler J et al: Imaging of cancer of the cervix. Radiol Clin
Women's Medicine. https://www.glowm.com/resources/ North Am. 40(3):577-90, vii, 2002
glowm/cd/pages/v4/v4c006.html. Accessed July 1, 2014 27. Pannu HK et al: CT evaluation of cervical cancer: spectrum
3. National Institutes of Health. Cervical cancer treatment. of disease. Radiographics. 21(5):1155-68, 2001
http://www.cancer.gov/cancertopics/pdq/treatment/ 28. Nicolet V et al: MR imaging of cervical carcinoma: a
cervical/HealthProfessional. Modified May 15, 2013. practical staging approach. Radiographics. 20(6):1539-49,
Accessed February 25, 2014 2000
4. Nucci M et al: Diagnostic Pathology: Gynecological. Salt 29. Yang WT et al: Comparison of dynamic helical CT and
Lake City, Utah: Amirsys Publishing, Inc. 2014 dynamic MR imaging in the evaluation of pelvic lymph
5. Nougaret S et al: Pearls and pitfalls in MRI of gynecologic nodes in cervical carcinoma. AJR Am J Roentgenol.
malignancy with diffusion-weighted technique. AJR Am J 175(3):759-66, 2000
Roentgenol. 200(2):261-76, 2013 30. Fulcher AS et al: Recurrent cervical carcinoma: typical and
6. Tirumani SH et al: Current concepts in the diagnosis and atypical manifestations. Radiographics. 19 Spec No:S103-16;
management of endometrial and cervical carcinomas. quiz S264-5, 1999
Radiol Clin North Am. 51(6):1087-110, 2013 31. Yamashita Y et al: Adenoma malignum: MR appearances
7. Balleyguier C et al: Staging of uterine cervical cancer with mimicking nabothian cysts. AJR Am J Roentgenol.
MRI: guidelines of the European Society of Urogenital 162(3):649-50, 1994
Radiology. Eur Radiol. 21(5):1102-10, 2011 32. Hricak H et al: Invasive cervical carcinoma: comparison
8. Beddy P et al: Role of MRI in intracavitary brachytherapy for of MR imaging and surgical findings. Radiology.
cervical cancer: what the radiologist needs to know. AJR Am 166(3):623-31, 1988
J Roentgenol. 196(3):W341-7, 2011 33. LaPolla JP et al: The influence of surgical staging on
9. Liu Y et al: Differentiation of metastatic from non- the evaluation and treatment of patients with cervical
metastatic lymph nodes in patients with uterine cervical carcinoma. Gynecol Oncol. 24(2):194-206, 1986
cancer using diffusion-weighted imaging. Gynecol Oncol. 34. Van Nagell JR Jr et al: The staging of cervical cancer:
122(1):19-24, 2011 inevitable discrepancies between clinical staging and
10. Ramirez PT et al: Laparoscopic extraperitoneal para-aortic pathologic findinges. Am J Obstet Gynecol. 110(7):973-8,
lymphadenectomy in locally advanced cervical cancer: a 1971
prospective correlation of surgical findings with positron
emission tomography/computed tomography findings.
Cancer. 117(9):1928-34, 2011
11. American Joint Committee on Cancer: AJCC Cancer Staging
12. Son H et al: PET/CT evaluation of cervical cancer: spectrum
of disease. Radiographics. 30(5):1251-68, 2010
13. Zand B et al: Rate of para-aortic lymph node micrometastasis
in patients with locally advanced cervical cancer. Gynecol
Oncol. 119(3):422-5, 2010
14. Rezvani M et al: Imaging of cervical pathology. Clin Obstet
Gynecol. 52(1):94-111, 2009
15. Schwarz JK et al: The role of 18F-FDG PET in assessing
therapy response in cancer of the cervix and ovaries. J Nucl
Med. 50 Suppl 1:64S-73S, 2009
16. Akin O et al: Imaging of uterine cancer. Radiol Clin North
Am. 45(1):167-82, 2007
17. Loft A et al: The diagnostic value of PET/CT scanning in
patients with cervical cancer: a prospective study. Gynecol
Oncol. 106(1):29-34, 2007
18. Sala E et al: MRI of malignant neoplasms of the uterine
corpus and cervix. AJR Am J Roentgenol. 188(6):1577-87,
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19. Amit A et al: The role of hybrid PET/CT in the evaluation of
patients with cervical cancer. Gynecol Oncol. 100(1):65-9,
2006
20. Unger JB et al: Detection of recurrent cervical cancer
by whole-body FDG PET scan in asymptomatic and
symptomatic women. Gynecol Oncol. 94(1):212-6, 2004
21. Yang DH et al: MRI of small cell carcinoma of the uterine
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182(5):1255-8, 2004
22. Jeong YY et al: Uterine cervical carcinoma after therapy:
CT and MR imaging findings. Radiographics. 23(4):969-81;
discussion 981, 2003
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CERVICAL CARCINOMA
Cervix
Stage IB1 (T1b1 N0 M0) Stage IB1 (T1b1 N0 M0)
shows a small hyperintense
cervical mass at the
expected location of the
squamocolumnar junction
in the ectocervix. (Right)
Coronal oblique (short axis)
patient shows the small
hyperintense cervical mass
.

(Left) Gross surgical specimen
the small exophytic mass
at the external os of
the cervix arising from the
expected location of the
squamocolumnar junction.
(Right) T2WI FSE MR shows
a hyperintense cervical mass
with preservation of a rim
of normal low-signal cervical
stroma .

shows a large exophytic
cervical mass expanding
the vaginal fornices. The
low signal vaginal wall
is preserved indicating
the tumor is confined to
the cervix. The marked T2
hyperintensity is typical of
adenocarcinoma. (Right)
Axial oblique T2WI FSE MR
residual normal low signal
cervix in the center of
the mass. Preservation of
the vaginal wall , bladder,
rectum, and uterosacral
ligaments are well seen in
the "donut" view.
3
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Obgyne Books Full

shows a hyperintense mass
with partial thickness
invasion of the posterior
cervix and preservation of
a rim of normal low-signal
stroma . (Right) Coronal
oblique (short axis) T2WI FSE
a hyperintense cervical mass
obliterating the normal
low signal stroma. Contrast
the superficial location of
nabothian cysts with the
deep invasion of the tumor.

(Left) T2WI FSE MR shows
an exophytic, hyperintense
cervical mass expanding the
vaginal fornices , though
without disruption of the low-
signal vaginal wall. Despite
the large size of the cervical
mass, this is a stage IB tumor
due to the lack of vaginal
invasion. (Right) T1WI C+
shows avid enhancement
of the exophytic cervical
mass . Post-contrast
images are typically not as
helpful in tumor staging. Note
preservation of the vaginal
wall is best seen on the T2WI.
Stage IIA1 (T2a1 N0 M0) Stage IIA1 (T2a1 N0 M0)

an exophytic cervical
mass invading the left and
posterior vaginal wall .
The parametrial fat
is normal in density and
symmetric, suggesting no
invasion. (Right) Axial CECT
in the same patient, slightly
more caudally, shows a
large exophytic cervical
mass without parametrial
invasion. Minimal gas and
fluid surround the mass in the
vaginal vault.
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CERVICAL CARCINOMA
Cervix
hypoenhancing mass
in the cervix. The mass is
difficult to see due to poor
soft tissue contrast, typical
of cervical cancer on CT.
(Right) Axial fused PET/
CT and PET in the same
patient clearly demonstrate
a hypermetabolic cervical
mass . No adenopathy or
metastatic disease was found.

shows a hyperintense,
partially exophytic cervical
mass . Thin smooth
uterosacral ligaments
and normal parametrial
fat indicate absence of
parametrial invasion. (Right)
Coronal oblique T2WI MR
a hyperintense, partially
exophytic cervical mass
focally invading the upper
vagina . Note preservation
of the normal low signal in
the remainder of the vaginal
wall.

FSE MR shows a hyperintense
cervical mass . The
parametrium-tumor interface
is sharp with preservation
of fat planes, suggesting no
invasion. Note normal thin
uterosacral ligaments .
(Right) Sagittal T2WI FSE
MR shows a large exophytic
cervical mass expanding
the vaginal fornices with
disruption of the normal low
signal vaginal wall . The
external contour of the tumor
is smooth, and parametrial fat
is preserved.
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shows a hyperintense cervical
mass invading the upper
anterior wall of the vagina
. Note distention of the
uterine cavity due to
obstruction by the cervical
mass. (Right) Gross surgical
specimen from hysterectomy
the large exophytic cervical
mass .
Stage IIB (T2b N0 M0) Stage IIB (T2b N0 M0)

FSE MR shows a hyperintense
mass obliterating the
cervix and invading the
parametrial tissues . (Right)
Axial CECT shows a cervical
mass with full thickness
cervical stromal invasion and
extension into the uterus .
The cervical contour is ill
defined, and the paracervical
fat is increased in density.
These nonspecific findings
can be due to parametrial
inflammation or tumor
invasion.

(Left) Coronal oblique
T2WI FSE MR (long axis)
shows an exophytic cervical
mass expanding the left
vaginal fornix . There is
full thickness invasion on the
left with tumor extension into
the parametrium . (Right)
Coronal oblique T2WI FSE
MR (donut view) in the same
patient shows the cervical
mass disrupting the normal
stroma and expanding the
endocervical canal. Note the
contrast between the normal
hypointense cervical stroma
and the hyperintense mass
.
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CERVICAL CARCINOMA
Cervix
FSE MR shows full thickness
invasion of the cervix by a
hyperintense mass with frank
tumor extension into
the parametrium bilaterally.
shows a large hyperintense
cervical mass that invades the
parametrial fat posteriorly ,
along with the lower uterine
segment and upper vagina
. Note preservation of an
intervening fat plane between
the tumor and the normal
low-signal urinary bladder
wall and rectum.
Stage IIIA (T3a N0 M0) Stage IIIA (T3a N0 M0)

shows a hyperintense cervical
mass invading the anterior
vaginal wall with extension to
the lower 1/3 of the vagina
. The low-signal urinary
bladder wall is intact.
shows a large cervical mass
expanding and invading
the vagina caudally to the
level of the introitus .
Stage IIIB (T1b1 N1 M0) Stage IIIB (T2b N1 M0)

(Left) Axial fused PET/CT
in a patient with clinical
stage IB disease shows
enlarged left pelvic lymph
nodes with increased FDG
activity . Regional lymph
node metastasis upstages
the patient to stage IIIB,
which requires radiation
and chemotherapy. (Right)
Axial T2WI FSE MR shows
an enlarged spherical left
external iliac lymph node .
Also note the T2 hyperintense
cervical mass invading the
vagina , lower uterine
segment , and parametrial
tissues .
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a postpartum patient shows
an exophytic cervical mass
extending into the vaginal
vault, as well as invading the
upper vagina and the
parametrial tissues on the left
. Note that the posterior
vaginal wall is intact.
(Right) Axial T2WI FSE MR in
the same patient shows left
external iliac adenopathy .
Note the enlarged postpartum
uterus .

MR shows a cervical mass
invading the upper vagina
. The urinary bladder is
decompressed with a Foley
catheter . (Right) Axial
same patient demonstrates
parametrial invasion of the
tumor bilaterally.

dilated ureters bilaterally,
although this is particularly
difficult to see in the bright
parametrial fat. (Right)
Coronal thick slab T2 FS is
helpful in showing bilateral
hydronephrosis. Although
right hydronephrosis and
hydroureter is obscured by
free fluid, the dilated left
ureter is well visualized.
Note Foley catheter balloon
in the urinary bladder.
Hydronephrosis can be
difficult to see due to the
typically small field of view of
pelvic MR.
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CERVICAL CARCINOMA
Cervix
heterogeneous cervical mass
with frank extension into the
paracervical fat on the right
. (Right) Coronal CECT in
the same patient shows right
ureteral dilation abruptly
terminating at the level of the
cervical mass , consistent
with right ureteral invasion
making this a FIGO stage IIIB
tumor.

MR shows a hyperintense
cervical mass invading the
upper vaginal anteriorly .
Preservation of the normal
low signal urinary bladder
wall indicates no mucosal
invasion. Note the utility
of instilling gel in the
vagina in aiding staging local
tumor extent. (Right) Coronal
same patient shows the tumor
invading the parametrial
fat bilaterally. Disruption of
the vaginal wall is also
seen.

shows right hydroureter
. The cervical mass
and vagina are
partially visualized. Note the
difficulty seeing the dilated
ureter in the background
of hyperintense fat. (Right)
Coronal thick slab T2 FS
shows right hydronephrosis
. Note the left kidney .
A fat-saturated T2WI of the
abdomen and pelvis is helpful
for identifying hydronephrosis
when imaging patients for
cervical cancer staging.
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heterogeneous cervical mass
placing mass effect on
the urinary bladder and
rectum without definite
mucosal invasion. (Right)
Axial CECT in the same
patient shows extension of the
cervical mass to encase
the right external iliac artery
, consistent with pelvic
sidewall invasion.
Stage IIIB With Bullous Edema Sign Stage IIIB With Bullous Edema Sign
shows a hyperintense
cervical mass invading
the vesicouterine ligament
. There is reactive T2
hyperintense thickening of
the urinary bladder mucosa
; however, no disruption of
the low signal wall is present
to suggest invasion. Left
hydronephrosis was seen
(not shown). (Right) Sagittal
T2WI MR after intravenous
contrast better demonstrates
the reactive urinary bladder
wall edema , which is
outlined by dense, low-signal
gadolinium.

replacement of the cervix
by a mass that invades
anteriorly into the urinary
bladder lumen . Note
nodular thickening of the
left uterosacral ligament
. (Right) Axial CECT
in the same patient after
administration of rectal
contrast better shows
eccentric wall thickening
of the left rectum and
luminal irregularity indicative
of mucosal invasion.
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CERVICAL CARCINOMA
Cervix
cervical mass extending
anteriorly to invade the
urinary bladder and
posteriorly to the rectal
mucosa . (Right) Axial
CECT shows the rectum
abutting the cervix with
no intervening fat plane.
There is a fluid- and gas-filled
tract extending from the
endocervical canal to the
rectum, consistent with a
fistula. Note fecal material
within the cervix.
Stage IVB (T1b2 N1 M1) Stage IVB (T1b2 N1 M1)

(Left) Axial CECT at the level
of the cervix in a patient with
clinical stage IB2 disease
demonstrates the limitations
of CT in visualizing cervical
masses. This patient had a
necrotic, 5.5 cm cervical
mass on physical exam.
same patient shows fluid
distension of the uterine
cavity , the only finding
that suggests a cervical mass
in this patient. The uterus is
retroflexed.
Stage IVB (T1b2 N1 M1) Stage IVB (T1b2 N1 M1)

patient shows interaortocaval
adenopathy , upstaging
this patient to stage IVB with
metastatic disease. (Right)
patient shows left external
iliac adenopathy and a
solid right ovarian mass .
Despite the poor performance
of CT in the evaluation
of the primary tumor, the
examination influenced
staging by revealing pelvic
adenopathy and metastatic
disease to the ovary and
paraaortic lymph nodes.
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Stage IVB (T1b2 N1 M1) Stage IVB (T2b N0 M1)

(Left) Whole-body PET image
shows overall disease burden
in a patient with metastatic
cervical cancer. Note the
FDG-avid primary tumor
, as well as metastases in
the inguinal, iliac, periaortic,
supraclavicular, and axillary
lymph nodes. (Right)
Coronal CECT shows an
enhancing urethral mass
cervical cancer. Also note
the peritoneal carcinomatosis
. Numerous pulmonary
nodules are not shown.
Stage IVB (T2a2 N1 M1) Stage IVB (T2a2 N1 M1)

in a patient with cervical
neuroendocrine carcinoma
cervical mass invading
the anterior wall of the upper
vagina. Note the packing
material in the vaginal vault
. Typically T2WI are not
fat-saturated to allow better
visualization of fat planes and
more accurate local tumor
staging. (Right) Sagittal T1WI
C+ FS MR shows to better
advantage the invasion of
the vaginal wall . Note
preservation of the posterior
vagina and packing
material in the vault.
Stage IVB (T2a2 N1 M1) Stage IVB (T2a2 N1 M1)

external iliac adenopathy .
Neuroendocrine carcinoma of
the cervix frequently presents
with adenopathy even when
the primary tumor is relatively
small. (Right) Axial fused
PET/CT in the same patient
shows a hypermetabolic
mass in the tail of the
pancreas. Although the
appearance of the primary
cervical tumor is nonspecific,
neuroendocrine cancers are
more aggressive and more
frequently metastatic at the
time of presentation.
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CERVICAL CARCINOMA
Cervix
Stage IVB (T2a N1 M1) Stage IVB (T2a2 N0 M1)
(Left) Whole-body PET
image shows FDG-avid,
subcentimeter common iliac
lymph nodes and lung
nodules . The patient was
upstaged from initial clinical
stage IIA to IVB, and the
treatment was changed from
curative to palliative. (Right)
Axial fused PET/CT shows
2 focal areas of increased
FDG activity in the liver ,
compatible with hepatic
metastatic disease.
Stage IVB (T2b N1 M1) Stage IVB (T2b N1 M1)

cervical mass. Irregularity
of the right tumor-fat
interface, increased density
of the parametrial fat ,
and thickening of the
right uterosacral ligament
are consistent with
parametrial invasion. The
left parametrial fat is
preserved. (Right) Axial PET/
CT in the same patient shows
the hypermetabolic cervical
mass . Small left obturator
and paraaortic
nodes are not enlarged but
hypermetabolic, upstaging
this patient.
Stage IVB (T2b N1 M1) Stage IVB (T2b N1 M1)

(Left) MR in the same
patient was performed to
confirm position of tandem
and ovoids and determine
dose for administration
of brachytherapy. Axial
image shows tandem
appropriately positioned
in the endocervical canal
and surrounded by mildly
hyperintense tumor .
(Right) Axial MR image in the
same patient shows ovoids
appropriately positioned
in the upper vagina.
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Distant Recurrence Distant Recurrence

with a history of squamous
cell cervical cancer treated
with radiation therapy shows
a cavitary lung nodule .
Cavitary lung metastases
are typical of squamous cell
primary malignancies. (Right)
Sagittal CECT in the same
patient shows the atrophy
of the uterus and cervix
without local recurrence.
Metastatic disease is usually
seen at recurrence. Only
10% of cervical cancer
patients have metastases at
the time of diagnosis.
Pelvic Sidewall Recurrence Pelvic Sidewall Recurrence

(Left) Coronal CECT shows
a mass in the right
hemipelvis invading the
iliacus and psoas muscles and
encasing the right iliac artery
. Obstruction of the ureter
is not included on this image;
however, hydronephrosis and
a delayed right nephrogram
are evident. (Right) Axial
shows the uterine fundus
. The cervix is severely
atrophic following radiation
therapy. There is right pelvic
sidewall recurrence .
Cystic Pelvic Sidewall Recurrence Central Recurrence

shows 2 cystic masses
at the left pelvic sidewall
in this patient with cervical
cancer status post remote
hysterectomy. Recurrence
may be solid or cystic,
as in this patient. (Right)
Axial CECT shows right
hydronephrosis with
obstruction of the ureter
by an irregular enhancing
mass at the right vaginal cuff.
The mass extends to the
obturator internus muscle,
to the thickened urinary
bladder and rectum with loss
of intervening fat planes.
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CERVICAL CARCINOMA
Cervix
MR in a patient with
cervical cancer shows the
normal post-trachelectomy
appearance with absence
of the cervix . (Right)
same patient, 1 year later,
demonstrates distension of
the uterine cavity with
fluid, concerning for tumor
recurrence and obstruction.
The vagina is distended with
gel in this protocol to
allow better visualization of
the cervix/trachelectomy site
and vagina.
shows the uterine cavity
distended with fluid,
and stenosis with an
associated T2-hyperintense
exophytic mass at the
level of the trachelectomy.
Note the utility of distending
the vagina with gel.
(Right) Axial oblique T2WI
at the level of the stenosis
shows the exophytic
recurrent tumor and
pelvic adenopathy .
MR shows the distended
uterine cavity , enhancing
exophytic recurrent tumor
, left external iliac
adenopathy , and left
ovarian metastasis .
FS MR shows the portion
of the recurrent mass
at the trachelectomy site
with invasion of the vaginal
cuff and resultant stenosis.
Thickening of the posterior
uterine wall is concerning
for tumor infiltration. Ovarian
metastasis is again noted.
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Cervix ADENOMA MALIGNUM
Key Facts
Terminology • As it presents with cluster of cysts, it has a deceptively
• Subtype of mucinous adenocarcinoma of cervix benign histologic appearance, which occasionally
leads to incorrect diagnosis
o Termed malignum due to virulent and fatal
progression of tumor • Associated with
o Peutz-Jeghers syndrome (mucocutaneous
Imaging pigmentation and multiple hamartomatous polyps
• Multicystic lesions that extend from endocervical of intestinal tract)
o Mucinous tumors of ovary
glands to deep cervical stroma with solid components
• Enlarged cervix: Cluster of grape-like cysts within o Ovarian sex cord tumor with annular tubules
cervical stroma (SCTAT)
• Fluid (mucin) within uterus &/or vagina may be Clinical Issues
present
• Low signal intensity cysts embedded in enhancing • Watery vaginal discharge
stroma • Menometrorrhagia
Pathology
• Prognosis is unfavorable as it disseminates into
peritoneal cavity in early stage of disease
• Composed of well-differentiated endocervical glands
that extend from surface to deeper portion of cervical
wall

centered at the cervix in a 43-
year-old woman presenting
with profuse watery vaginal
discharge shows several T1WI
hypointense cysts clustered
centrally . Surgical resection
proved to be adenoma
malignum subtype. (Right)
same patient with adenoma
malignum shows the grape-
like cluster of T2-bright cysts
expanding the cervix and
extending into the cervical
stroma . Note the solid
elements within the cystic
mass .

a 56-year-old woman with
vaginal bleeding shows a
large T2 hyperintense soft
tissue mass replacing the
normal T2 dark cervical
stroma without invasion
of the parametrium. Surgical
resection proved to be
adenoma malignum. (Right)
same patient shows a large T2
hyperintense soft tissue mass
replacing the normal T2 dark
cervical stroma without
invasion of the parametrium.
adenoma malignum.
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ADENOMA MALIGNUM
Cervix
TERMINOLOGY • Protocol advice
o Dedicated pelvic MR with phased-array coil, 4-5 mm
Synonyms slice thickness
• Mucinous minimal deviation adenocarcinoma ▪ Axial T1WI with larger field of view (FOV) from
o Mucoid adenocarcinoma pelvis to kidneys for lymph nodes
▪ Axial, sagittal, and coronal (short-axis) T2WI with
Definitions small FOV
• Subtype of mucinous adenocarcinoma of cervix ▪ Sagittal and coronal (short-axis) dynamic T1WI C+
o Termed malignum because of virulent and fatal FS with small FOV
progression of tumor
IMAGING
Nabothian Cysts
General Features • Mucous retention cyst formed as a result of healing
• Best diagnostic clue from chronic cervicitis
o Multicystic lesions that extend from endocervical • Superficial epithelial cysts of variable sizes
glands to deep cervical stroma with solid o Deep-seated cysts are problematic
components
o Enlarged cervix: Cluster of grape-like cysts within
• "Tunnel cluster" is a special type of nabothian cyst that
has a multilocular appearance and mimics adenoma
cervical stroma malignum on macroscopic section
o Fluid (mucin) within uterus &/or vagina may be
present
• Cervix may be enlarged
• Location Endocervical Glandular Hyperplasia With Gastric

o Cervix Metaplasia
CT Findings • Benign entity
o Can form cysts in endocervical canal
• NECT • No mucoid vaginal discharge
o Enlarged globular cervix
• CECT • Does not extend into uterus
o Low-attenuation cysts within enlarged cervix • Usually no solid components associated with
endocervical hyperplasia
MR Findings
• T1WI Cervical Cancer (Histology Other Than
Adenoma Malignum)
o Enlarged cervix with low signal intensity cysts
o Low signal intensity fluid may be present in uterus &/ • Invasive solid cervical mass
or vagina o Can extend to uterus &/or vagina
• T2WI ▪ May have associated pelvic lymphadenopathy
o Cluster of high signal intensity cysts within low • Usually no cystic components
signal intensity stroma Cervical Lymphoma
▪ Cysts can vary in size
o "Cluster of cysts" extends from endocervical glands to • Solid mass diffusely involving cervix
o Typically not cystic in nature
deep cervical stroma
• DWI
o Demonstrates restriction PATHOLOGY
• T1WI C+
General Features
o Low signal intensity cysts embedded in enhancing
stroma • Etiology
o Multicystic lesions that extend from endocervical o ~ 3% of all cervical adenocarcinomas
glands to deep cervical stroma with solid • Associated abnormalities
o Peutz-Jeghers syndrome (mucocutaneous
components
pigmentation and multiple hamartomatous polyps
Ultrasonographic Findings of intestinal tract)
• Grayscale ultrasound ▪ Relatively frequent occurrence of cervical adenoma
o May see cystic mass in cervix malignum in women with Peutz-Jeghers syndrome
• Color Doppler warrants close surveillance by gynecologists for
o May have internal vascularity early detection
o Mucinous tumors of ovary
Nuclear Medicine Findings o Ovarian sex cord tumor with annular tubules
• PET (SCTAT)
o FDG-18 avid
▪ PET/CT useful to detect metastases
• Deceptively benign histologic appearance occasionally
leads to incorrect diagnosis
o Highly aggressive behavior
• Best imaging tool • Difficult diagnosis on regular "punch" biopsy,
o MR Papanicolaou smear, or colposcopy
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Cervix ADENOMA MALIGNUM
• Imaging findings guide deep cervical stromal biopsy 2. Cole AJ et al: Patterns of myoinvasion in endometrial
adenocarcinoma: recognition and implications. Adv Anat
Gross Pathologic & Surgical Features Pathol. 20(3):141-7, 2013
• Cervix is enlarged, firm, and indurated 3. Guo F et al: Diagnostic challenges in minimal deviation
• Mucosal surface may be hemorrhagic, friable, or adenocarcinoma of the uterine cervix: A report of two cases
and review of the literature. Mol Clin Oncol. 1(5):833-838,
mucoid
• Cysts are embedded deeply in cervical stroma
2013
4. Khalbuss WE et al: Cytomorphology of unusual primary
• Forms annular or nodular mass, with cystic spaces filled tumors in the Pap test. Cytojournal. 10:17, 2013
with mucin 5. Ki EY et al: Adenoma malignum of the uterine cervix: report
of four cases. World J Surg Oncol. 11:168, 2013
Microscopic Features 6. Kwon SY et al: Minimal deviation adenocarcinoma of
• Composed of well-differentiated endocervical glands the cervix and tumorlets of sex-cord stromal tumor with
that extend from surface to deeper portion of cervical annular tubules of the ovary in Peutz-Jeghers syndrome. J
wall Gynecol Oncol. 24(1):92-5, 2013
• Cysts are irregular in size and shape, lined by mucin- 7. McCluggage WG: New developments in endocervical
glandular lesions. Histopathology. 62(1):138-60, 2013
containing columnar epithelial cells
o Typical deep invasion of cervical wall 8. McCluggage WG: Premalignant lesions of the lower
•
female genital tract: cervix, vagina and vulva. Pathology.
Mucinous glands, majority of which have a deceptively 45(3):214-28, 2013
benign histological appearance 9. McEachern J et al: Adenoma malignum detected on a
• Form annular or nodular mass, with cystic spaces filled trauma CT. J Radiol Case Rep. 7(4):22-8, 2013
with mucin 10. Park SB et al: Adenoma malignum of the uterine cervix:
imaging features with clinicopathologic correlation. Acta
Radiol. 54(1):113-20, 2013
CLINICAL ISSUES 11. Dasgupta S et al: Adenoma malignum of the uterine cervix--
an enigma. J Indian Med Assoc. 110(12):929-30, 2012
Presentation 12. Ito M et al: Peutz-Jeghers syndrome-associated atypical
• Most common signs/symptoms mucinous proliferation of the uterine cervix: a case of
o Watery vaginal discharge minimal deviation adenocarcinoma ('adenoma malignum')
o Menometrorrhagia in situ. Pathol Res Pract. 208(10):623-7, 2012
o Abdominal swelling 13. Lim KT et al: Adenoma malignum of the uterine cervix:
o Systemic symptoms suggests advanced disease Clinicopathologic analysis of 18 cases. Kaohsiung J Med Sci.
•
28(3):161-4, 2012
Other signs/symptoms 14. Quick CM et al: Low-grade, low-stage endometrioid
o Can present with elevated carcinoembryonic antigen endometrial adenocarcinoma: a clinicopathologic
• Clinical profile analysis of 324 cases focusing on frequency and pattern of
o May have history of Peutz-Jeghers syndrome myoinvasion. Int J Gynecol Pathol. 31(4):337-43, 2012
15. Shiozawa T: [Adenoma malignum and lobular endocervical
Demographics glandular hyperplasia (LEGH).] Nihon Rinsho. 70 Suppl
• Age 4:114-21, 2012
o Age range: 25-72 years (average: 42) 16. Park SB et al: Adenoma malignum of the uterine cervix:
• Ethnicity
ultrasonographic findings in 11 patients. Ultrasound Obstet
Gynecol. 38(6):716-21, 2011
o No ethnic predilection 17. Sharp HJ et al: PET/CT in a patient with adenoma malignum
of the uterine cervix. Clin Nucl Med. 36(6):468-9, 2011
• Prognosis is unfavorable as it disseminates into
18. Takatsu A et al: Preoperative differential diagnosis
of minimal deviation adenocarcinoma and lobular
peritoneal cavity in early stage of disease endocervical glandular hyperplasia of the uterine cervix:
• Indolent compared to more common squamous cell a multicenter study of clinicopathology and magnetic
cervical cancer resonance imaging findings. Int J Gynecol Cancer.
• Poor response to radiation and chemotherapy 19.
21(7):1287-96, 2011
Bin Park S et al: Multilocular cystic lesions in the uterine
Treatment cervix: broad spectrum of imaging features and pathologic
• Surgery correlation. AJR Am J Roentgenol. 195(2):517-23, 2010
• Adjuvant radiation and chemotherapy 20. Li G et al: Minimal deviation adenocarcinoma of the uterine
cervix. Int J Gynaecol Obstet. 110(2):89-92, 2010
21. Sugiyama K et al: MR findings of pseudoneoplastic lesions
in the uterine cervix mimicking adenoma malignum. Br J
DIAGNOSTIC CHECKLIST Radiol. 80(959):878-83, 2007
Consider 22. Ohta Y et al: Cytology, immunohistochemistry and 3-
• Multicystic lesions that extend from endocervical dimensional reconstruction of adenoma malignum: a case
report. Acta Cytol. 49(2):181-6, 2005
glands to deep cervical stroma with solid components 23. Oguri H et al: MRI of endocervical glandular disorders:
three cases of a deep nabothian cyst and three cases of a
• "Cluster of cysts" embedded in cervical stroma
minimal-deviation adenocarcinoma. Magn Reson Imaging.
22(9):1333-7, 2004
SELECTED REFERENCES
1. Mowat A et al: Adenoma malignum presenting as urinary
3 incontinence. Int Urogynecol J. Epub ahead of print, 2014
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ADENOMA MALIGNUM
Cervix
in a patient with adenoma
malignum shows a well-defined
T2 hyperintense solid mass
expanding the cervix and
replacing the normal T2 dark
cervical stroma. (Right) Sagittal
T1WI FSE MR in a woman
presenting with vaginal bleeding
shows a small cluster of T2
hyperintensity in the endocervix
and embedded in the cervical
stroma .

adenoma malignum shows
the grape-like cluster of T2-
bright cysts expanding the
cervix and extending into the
cervical stroma . Note the
solid elements within the mass
inferiorly . (Right) Sagittal
patient with adenoma malignum
shows the grape-like cystic
mass with enhancing soft tissue
septations expanding the
cervix and extending into the
endocervical stroma.

a patient who presented with
vaginal bleeding shows an ill-
defined, somewhat necrotic
mass replacing the normal
cervical stroma . Surgical
resection proved to be adenoma
malignum. (Right) Axial T1 C+ FS
MR in a woman presenting with
diffuse watery vaginal discharge
shows a large, round, enhancing
soft tissue cervical mass with
invasion of the left parametrium
.
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Cervix CERVICAL SARCOMA
Key Facts
Terminology • Ewing sarcoma
• Group of rare mesenchymal tumors arising from cervix • Undifferentiated endocervical sarcoma
• Liposarcoma
Imaging • Malignant mixed mesenchymal tumors (MMMT)
• Heterogeneous enhancing mass arising from cervix,
can expand endocervical cavity Clinical Issues
• Diffusely infiltrating cervical tumor or polypoid mass; • Abnormal vaginal bleeding, pelvic pain
may extend to uterine corpus, vagina, or parametria • Long-term follow-up difficult due to rarity of sarcomas
• Heterogeneously enhancing pelvic mass due to regions • Patients tend to develop hematogenous metastases
of hemorrhage and necrosis
• Multimodality treatment including surgery (total
Top Differential Diagnoses abdominal hysterectomy ± bilateral salpingo-
• Cervical carcinoma oophorectomy ± pelvic lymphadenectomy),
chemotherapy, and radiotherapy
Pathology Diagnostic Checklist
• Rhabdomyosarcoma • Polypoid or diffusely infiltrating mass involving cervix
• Leiomyosarcoma with heterogeneous T1 and T2W signal intensity and
• Malignant peripheral nerve sheath tumor heterogeneous enhancement

menorrhagia shows a uterine
fundal fibroid and a large
T2-hyperintense mass .
Surgical resection proved to
be a leiomyosarcoma of the
cervix (Right) Sagittal T2WI
with cervical leiomyosarcoma
shows the dominant T2-
hyperintense mass
replacing the entire cervix

T2-hyperintense mass
canal. Surgical pathology
proved a malignant mixed
mesodermal tumor arising
from the cervix. (Right) Axial
T1WI C+ FS MR image in the
same patient with malignant
mixed mesodermal tumor
of the cervix shows the
of the tumor with central
regions of necrosis .
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CERVICAL SARCOMA
Cervix
TERMINOLOGY PATHOLOGY
Definitions Gross Pathologic & Surgical Features
• Group of rare mesenchymal tumors arising from cervix • Rhabdomyosarcoma
o Botryoid type appears as intraluminal mass
composed of smooth grape-like clusters
IMAGING
•Leiomyosarcoma
General Features o Large (~10 cm), poorly circumscribed mass that
• Best diagnostic clue either protrudes from cervical canal or diffusely
o Heterogeneous enhancing mass arising from cervix expands it circumferentially
• Location •Malignant peripheral nerve sheath tumor
o Cervix o Polypoid masses, may cross interfascial planes
• Size •Ewing sarcoma
o Variable, depending on histology; can be > 10 cm o Well-circumscribed mass of ~ 5-6 cm in size
• Morphology •Alveolar soft part sarcoma
o Diffusely infiltrating cervical tumor or polypoid mass o Well-circumscribed mass with mean size of 2.4 cm
▪ Can expand endocervical cavity •Undifferentiated endocervical sarcoma
o Variable appearance: Protruding polypoid masses,
CT Findings with regions of hemorrhage, ulceration, necrosis
• Heterogeneously enhancing pelvic mass •Liposarcoma
MR Findings o Protuberant polypoid masses with macroscopic fat
• Mass of variable size •
and hemorrhage
Malignant mixed carcinosarcoma tumor
o May appear polypoid (e.g., botryoid subtype of
o Large polypoid or pedunculated mass with solid and
embryonal rhabdomyosarcoma)
o Heterogeneous low signal intensity (SI) on T1WI, necrotic areas
high signal intensity on T2WI, and post-contrast Microscopic Features
images
o Heterogeneity due to areas of hemorrhage and
• Rhabdomyosarcoma
o Divided into embryonal (70%), alveolar (20%), and
necrosis and presence of fat in liposarcoma
•
undifferentiated subtypes (10%)
May extend into uterine corpus, vagina, or parametria ▪ Botryoid subtype accounts for 10% of embryonal
Ultrasonographic Findings tumors and arise under mucosal surface
o Tumor cells analogous to various maturational stages
• Polypoid or diffusely infiltrating cervical mass of of fetal muscle cells (rhabdomyoblasts)
heterogeneous echotexture
o Range in appearances from primitive mesenchymal
Imaging Recommendations tumors with stellate cells to well-differentiated
• Best imaging tool lesions with myofiber-like cells and cross striations
o MR o Immunohistochemistry: Antibodies directed toward
▪ For local staging and treatment planning myoglobin, desmin, actin, and the MYOD1 gene
• Protocol advice product
o T1WI: Axial, large field of view (FOV) •Leiomyosarcoma
o T2WI: Axial, sagittal, small FOV o Histological subtypes include myxoid variant, and
o T2WI: Axial oblique and coronal oblique images epithelioid variant with abundance of xanthomatous
perpendicular and parallel to cervix cells and osteoclast-like giant cells
o T1 C+ FS: Axial, small FOV •Malignant peripheral nerve sheath tumor
▪ DWI imaging useful o Differentiation toward cells intrinsic to peripheral
nerve sheath
o Spindle cells may be arranged in herringbone,
nodular, or storiform fascicles
Cervical Carcinoma o In contrast to other sarcomas, cells tend to infiltrate
• Carcinoma occurs much more commonly than but not destroy native endocervical glands
o Immunohistochemistry: Cells positive for S100
sarcoma
• Cervical carcinoma tends to be more homogeneous (not always) and vimentin; negative for desmin,
than cervical sarcoma myoglobin, and actin
Cervical Lymphoma
•Ewing sarcoma
o Cells show varying degrees of neuroectodermal
• Homogeneous bulky mass of high signal intensity on differentiation
T2WI
• Enlarged lymph nodes in cases of secondary lymphoma •Alveolar soft part sarcoma
o Composed of large cells with eosinophilic or granular
Cervical Metastasis cytoplasm arranged in solid &/or alveolar nests
• Mass of heterogeneous high SI on T2WI •Undifferentiated endocervical sarcoma
• Primary tumor may be evident o No specific line of differentiation
o Moderate to high grade
3
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Cervix CERVICAL SARCOMA
• Liposarcoma Natural History & Prognosis

o Includes pleomorphic, round cell, and well- • Long-term follow-up difficult due to rarity of sarcomas
differentiated fat attenuation • Patients tend to develop hematogenous metastases
•Malignant mixed carcinosarcoma tumors (MMMT)
• Prognosis depends on histology and is variable
o Combination of malignant epithelial and
mesenchymal components
• Disease-free intervals between 1 year to > 8 years
reported
o Epithelial component includes squamous cell
carcinoma, basaloid squamous carcinoma,
• Rhabdomyosarcoma
o Botryoid subtype associated with very good outcome
adenocarcinoma, adenosquamous carcinoma, o Alveolar and undifferentiated associated with poor
adenoid basal carcinoma, adenoid cystic carcinoma,
outcomes
and undifferentiated carcinoma o 5 years survival in > 50% for patients with metastatic
o Sarcomatous component may be homologous
embryonal subtype
(fibroblasts and smooth muscle) or heterologous
(cartilage, striated muscle, bone, etc.) • Cervical alveolar soft part sarcoma may have better
o Spectrum of malignancy: Includes adenosarcoma of prognosis than soft tissue counterpart
o Tends to be slow growing; can develop local and
relatively low-grade malignancy to highly aggressive
distant metastases
malignant mixed müllerian tumor
o Immunohistochemistry: Positive for cytokeratin; • Malignant mixed müllerian tumor may have better
prognosis than uterine counterpart
sarcomatous components may be positive for
vimentin, desmin, muscle-specific actin (MSA), and Treatment
smooth muscle-specific actin (SMA) • Multimodality treatment including surgery (total
abdominal hysterectomy ± bilateral salpingo-
oophorectomy ± pelvic lymphadenectomy)
CLINICAL ISSUES
• Combination chemotherapy (neoadjuvant) and
Presentation radiotherapy
o Abnormal vaginal bleeding DIAGNOSTIC CHECKLIST
o Pelvic pain
•Other signs/symptoms Consider
o Vaginal discharge • Sarcoma is a rare cause of patient presenting with
cervical (polypoid) mass
Demographics
• Age Image Interpretation Pearls
o Depends on histology • Polypoid or diffusely infiltrating mass involving cervix
▪ Rhabdomyosarcoma: First 2 decades of heterogeneous signal intensity on T1 and T2WI and
▪ Leiomyosarcoma: 4th-6th decades showing heterogeneous enhancement
▪ Undifferentiated endocervical sarcoma: 29-72 • May show local or distant spread
years (mean: 51 years)
▪ Alveolar soft part sarcoma: 8-39 years (mean: 30 SELECTED REFERENCES
years)
▪ Ewing sarcoma: 21-51 years (mean: 38 years) 1. Kirsch CH et al: Outcome of female pediatric patients
▪ Malignant peripheral nerve sheath tumor: 25-73 diagnosed with genital tract rhabdomyosarcoma based on
analysis of cases registered in SEER database between 1973
years (mean: 50 years) and 2006. Am J Clin Oncol. 37(1):47-50, 2014
▪ Liposarcoma: 45-62 years (mean: 54 years) 2. Dehner LP et al: Embryonal rhabdomyosarcoma of the
▪ Malignant mixed müllerian tumor: 12-93 years uterine cervix: a report of 14 cases and a discussion of its
(mean: 65 years) unusual clinicopathological associations. Mod Pathol.
•Gender 25(4):602-14, 2012
o Females 3. Khosla D et al: Sarcomas of uterine cervix:
•Epidemiology
clinicopathological features, treatment, and outcome. Int J
Gynecol Cancer. 22(6):1026-30, 2012
o Sarcomas account for ~ 0.5% of all malignancies 4. Qiu LL et al: Sarcomas of abdominal organs: computed
arising in cervix tomography and magnetic resonance imaging findings.
o Reported frequencies in literature Semin Ultrasound CT MR. 32(5):405-21, 2011
▪ Embryonal rhabdomyosarcoma: 64% 5. Chiang YC et al: Cervical granulocytic sarcoma: report of
▪ Leiomyosarcoma: 13% one case and review of the literature. Eur J Gynaecol Oncol.
▪ Undifferentiated endocervical sarcoma: 7% 31(6):697-700, 2010
▪ Alveolar sarcoma: 5% 6. Scaravilli G et al: Case report of a sarcoma botryoides of
the uterine cervix in fertile age and literature review. Arch
▪ Ewing sarcoma (primitive neuroectodermal Gynecol Obstet. 280(5):863-6, 2009
tumor): 4% 7. Fadare O: Uncommon sarcomas of the uterine cervix: a
▪ Malignant peripheral nerve sheath tumor: 3% review of selected entities. Diagn Pathol. 1:30, 2006
▪ Liposarcoma: 2% 8. Maheshwari A et al: Diagnostic dilemma in a case of
▪ Others: 2% (e.g., myeloid [granulocytic] sarcoma, malignant mixed mullerian tumor of the cervix. World J
chondrosarcoma, MMMT) Surg Oncol. 4:36, 2006
9. Pathak B et al: Granulocytic sarcoma presenting as tumors of
3 the cervix. Gynecol Oncol. 98(3):493-7, 2005
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CERVICAL SARCOMA
Cervix
(Left) Axial DWI MR image in
a patient with leiomyosarcoma
of the cervix shows marked
diffusion of the primary tumor
with tumor extending into the
parametrium . (Right) Coronal
T2WI FSE MR image in the same
patient with malignant mixed
mesodermal tumor (MMMT) of
the cervix shows heterogeneous
enhancement of the MMMT
with central regions of necrosis
.
(Left) Axial T2WI FSE MR image

of carcinosarcoma of the cervix
shows a large lobulated T2-
hyperintense mass replacing
the cervix, with extension to
the pelvic sidewall . (Right)
Axial FDG PET/CT images show
avid FDG-18 uptake within the
primary cervical stromal sarcoma
and inguinal nodes .
(Left) Axial CECT image of the

pelvis shows a large necrotic
mass expanding the cervical
cavity and invading the
myometrium . Surgical
resection proved it to be a
MMMT of the cervix. (Right)
shows tumor growth of the
cervical sarcoma anteriorly into
the pelvic cavity . Note the
necrotic nature of the MMMT of
the cervix
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Cervix CERVICAL MELANOMA
Key Facts
• Primary cervical melanoma • Squamous carcinoma
o Can be melanotic or amelanotic • Metastatic malignant melanoma
Imaging • Lymphoma
• Variable size • Sarcoma
• Polypoid exophytic mass Pathology
• T1WI: Cervical mass of high signal intensity with • FIGO staging system used
melanotic type
o Due to paramagnetic effects of stable free radicals Clinical Issues
within melanin granules or methemoglobin within • Vaginal bleeding/discharge
area of intratumoral hemorrhage • Average presentation in 5th decade
• T2WI: Cervical mass of high signal intensity • Rare tumor
• Heterogeneous or homogeneous enhancement • Most patients die within 3 years
• US: Cervical mass of heterogeneous echogenicity • Radical hysterectomy ± paraaortic and pelvic
• PET/CT: Sensitivity, specificity, and accuracy ranges lymphadenectomy if nodes are enlarged
from 70-100% • Chemotherapy ± immuno/biological therapy

a patient with recurrent
cervical melanoma shows
a large cervical mass of
heterogeneous, though
predominantly high, signal
intensity extending into the
bladder . (Right) Sagittal
shows a recurrent tumor
involving the cervix and
extending into the bladder
base , causing bladder
outlet obstruction.

with vaginal discharge and
was found to have a black-
colored polypoid cervical
lesion shows a rounded
mass within the posterior
aspect of the cervix. (Right)
Sagittal CECT in the same
patient shows a cervical
mass bulging into the
lower uterine segment and
causing obstruction of the
uterine cavity with a moderate
amount of endometrial fluid
accumulation .
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CERVICAL MELANOMA
Cervix
TERMINOLOGY • Heterogeneous enhancement
• Usually more infiltrative plaque-like or polypoid
Definitions growth pattern
• Primary cervical melanoma Metastatic Malignant Melanoma
o Can be melanotic or amelanotic
• Cervical mass of high signal intensity on T1WI,
variable signal intensity on T2WI (depending on
IMAGING melanin content)
• Presence or history of cutaneous melanoma
General Features
• Best diagnostic clue • ± disseminated metastases
o Cervical mass of high signal intensity on T1WI and • Absence of junctional activity on histology; neoplastic
cells localized below basement membrane
high signal intensity on T2WI
• Size Lymphoma
o Variable • Homogeneous bulky mass of low signal intensity on
• Morphology T1WI and high signal intensity on T2WI
o Polypoid exophytic mass • Associated lymphadenopathy if secondary
o Ulcerative involvement with lymphoma
o Infiltrative
Sarcoma
CT Findings • Heterogeneous enhancing cervical mass of variable
• Heterogeneously enhancing cervical mass signal intensity
• ± enlarged pelvic or paraaortic nodes
• ± disseminated hematogenous metastases PATHOLOGY
MR Findings Staging, Grading, & Classification
• T1WI • FIGO staging system used rather than Clark or Breslow
o Melanotic type: Cervical mass of high signal staging classification
intensity
▪ Due to paramagnetic effects of stable free radicals
within melanin granules or methemoglobin • Exophytic friable polypoid mass
within area of intratumoral hemorrhage • Areas of ulceration and hemorrhage
o Amelanotic type: Cervical mass of intermediate to • Blue/black/red/brown/gray discoloration in melanotic
low signal intensity form
• T2WI • Colorless in amelanotic form (~ 50% of total)
o Cervical mass of high signal intensity
• T1WI C+ FS
• Arises from melanotic cells of cervix
o Heterogeneous or homogeneous enhancement
• Diagnosis made on having following 4 criteria
Ultrasonographic Findings o Presence of melanin in normal cervical epithelium
• Grayscale ultrasound o Absence of melanoma elsewhere in body
o Demonstration of junctional change in cervix
o Cervical mass of heterogeneous echogenicity
• Color Doppler ▪ May be absent if surface ulceration
o Metastasizes according to pattern of cervical
o Cervical mass demonstrates variable vascularity
carcinoma
Nuclear Medicine Findings • Variable degree of pleomorphism; prominent nucleoli
• PET • Electron microscopy
o Can be used for staging in recurrent melanoma o Premelanosomes and mature melanosomes present
o Complements CT and MR o No epithelial structural differentiation
o Sensitivity, specificity, and accuracy ranges from
• Immunohistochemistry
70-100% o Nerve tissue protein S100 positive in most cases
o Sensitive for soft tissue and lymph node metastases o Monoclonal antibodies HMB-45 and Melan-A
o False negatives with lesions ≤ 1 cm in size
positive in most cases
Imaging Recommendations o Negative for epithelial markers
o MR for detection of tumor and local staging CLINICAL ISSUES
o CT used to demonstrate presence of lymphatic or
hematogenous metastases Presentation
o Vaginal bleeding/discharge
Squamous Carcinoma o Postcoital bleeding
• Cervical mass of heterogeneous low signal intensity on o Asymptomatic; detected on routine screening
T1WI and high signal intensity on T2WI
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Cervix CERVICAL MELANOMA
Demographics 6. Jin B et al: Primary melanoma of the uterine cervix after

• Age supracervical hysterectomy. A case report. Acta Cytol.
51(1):86-8, 2007
o 3rd to 8th decade; average 5th decade 7. Belhocine TZ et al: Role of nuclear medicine in the
• Epidemiology management of cutaneous malignant melanoma. J Nucl
o Rare tumor, mainly reported as case reports Med. 47(6):957-67, 2006
o Melanoma of female genital tract accounts for 1-5% 8. Mousavi AS et al: Primary malignant melanoma of the
of all melanoma cases; of this, 9-13% involve cervix uterine cervix: case report and review of the literature. J Low
o 5x more rare than primary melanoma of vagina and Genit Tract Dis. 10(4):258-63, 2006
9. Wydra D et al: Malignant melanoma of the uterine cervix.
vulva Eur J Obstet Gynecol Reprod Biol. 124(2):257-8, 2006
o ~ 60 cases of primary melanoma of female genital 10. Gupta R et al: Primary malignant melanoma of cervix - a
tract in literature case report. Indian J Cancer. 42(4):201-4, 2005
11. Ma SQ et al: Clinical analysis of primary malignant
• 50% of all cases show vaginal involvement (stage II)
melanoma of the cervix. Chin Med Sci J. 20(4):257-60, 2005
12. Siozos C et al: Malignant melanoma of the uterine cervix. J
• Recurs early after treatment Obstet Gynaecol. 25(8):826-7, 2005
• 5-year survival rate 13. Kudrimoti J et al: Primary malignant melanoma of cervix: a
o Stage I: 25% case report. Indian J Pathol Microbiol. 47(2):257-8, 2004
14. Saikia UN et al: Melanin containing cells of the uterine
o Stage II: 14%
cervix and a possible histogenesis--a case report. Indian J
o Stage III and IV: 0% Pathol Microbiol. 47(1):22-3, 2004
• Average survival: 6 months to 14 years 15. Makovitzky J et al: Primary malignant melanoma of the
• Most patients die within 3 years cervix uteri: a case report of a rare tumor. Anticancer Res.
23(2A):1063-7, 2003
Treatment 16. Okamoto Y et al: MR imaging of the uterine cervix: imaging-
• Radical hysterectomy pathologic correlation. Radiographics. 2003
• Paraaortic and pelvic lymphadenectomy if enlarged 17. Deshpande AH et al: Primary malignant melanoma of the
uterine cervix: report of a case diagnosed by cervical scrape
nodes
• External &/or intracavitary radiotherapy or both
cytology and review of the literature. Diagn Cytopathol.
25(2):108-11, 2001
• Chemotherapy combined with dimethyl triazeno 18. Furuya M et al: Clear cell variant of malignant melanoma of
imidazole carboxamide (DTIC) the uterine cervix: a case report and review of the literature.
o Dacarbazine shown to give response rates of 15-20% Gynecol Oncol. 80(3):409-12, 2001
• Immuno/biological therapy 19. Clark KC et al: Primary malignant melanoma of the uterine
cervix: case report with world literature review. Int J Gynecol
o Interleukin-2 and gamma interferon, Bacille-
Pathol. 18(3):265-73, 1999
Calmette-Guérin (BCG) or activated lymphocyte 20. Takehara M et al: Primary malignant melanoma of the
transfusion uterine cervix: a case report. J Obstet Gynaecol Res.
25(2):129-32, 1999
21. Wasef WR et al: Primary malignant melanoma of the cervix
DIAGNOSTIC CHECKLIST uteri. J Obstet Gynaecol. 19(6):673-4, 1999
22. Teixeira JC et al: Primary melanoma of the uterine cervix
Consider
• Primary melanoma of cervix when pigmented
figo stage III B. Sao Paulo Med J. 116(4):1778-80, 1998
23. Chang SC et al: Primary malignant melanoma of the vagina
tumor mass seen arising from cervix on speculum and cervix uteri: case report and literature review. Zhonghua
examination Yi Xue Za Zhi (Taipei). 50(4):341-6, 1992
o In absence of melanoma elsewhere 24. Yu HC et al: Detection of malignant melanoma of the
o Junctional change present in cervix uterine cervix from Papanicolaou smears. A case report. Acta
o Metastatic spread follows pattern for cervical Cytol. 31(1):73-6, 1987
carcinoma
• Classically, melanotic-type cervical melanoma
demonstrates high signal on T1WI and high signal
intensity on T2
SELECTED REFERENCES
1. Calderón-Salazar L et al: Primary malignant melanoma of
the uterine cervix treated with ultraradical surgery: a case
report. ISRN Obstet Gynecol. 2011:683020, 2011
2. Zhang J et al: A peculiar site: melanoma of the cervix. Am J
Obstet Gynecol. 205(5):508, 2011
3. Das P et al: Primary malignant melanoma at unusual
sites: an institutional experience with review of literature.
Melanoma Res. 20(3):233-9, 2010
4. An J et al: Primary malignant amelanotic melanoma of
the female genital tract: report of two cases and review of
literature. Melanoma Res. 19(4):267-70, 2009
3 5. Sugiyama VE et al: Management of melanomas of the female

genital tract. Curr Opin Oncol. 20(5):565-9, 2008
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CERVICAL MELANOMA
Cervix
year-old woman with vaginal
discharge shows a well-defined
cervical mass with high
signal intensity. The mass is
eccentric and not centered
on the cervical canal. (Right)
patient shows a well-defined
eccentric mass occupying
the posterior lip of the cervix.
Cervical melanomas usually
show high signal intensity on
T2WI; however, they may have
low signal intensity according to
the melanin concentration and
the presence of hemorrhage.

patient shows a cervical mass
demonstrating high signal
intensity relative to pelvic skeletal
muscles. The high signal intensity
within the urinary bladder is
due to gadolinium administrated
the day before for a brain MR.
cervical mass demonstrating
high signal intensity relative to
pelvic skeletal muscles. Cervical
melanomas usually have high T1
signal intensity.

homogeneously enhancing
cervical mass . (Right) Sagittal
patient shows a homogeneously
enhancing cervical mass .
Biopsy revealed melanotic
melanoma, and no other sites of
melanoma were found to suggest
metastatic disease.
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Cervix POST-TRACHELECTOMY APPEARANCES
Key Facts
Terminology • Postoperative complications
• Resection of cervix with end-to-end anastomosis of o
o
Isthmic stenosis
Vaginal wall hematoma
uterine corpus and vagina
o Lymphoceles
Imaging o Hydrosalpinx
• Performed for early stage cervical carcinoma (≤ IB1)
• Alternative to radical hysterectomy to preserve fertility Top Differential Diagnoses
• Recurrent tumor
• Radical trachelectomy and bilateral lymphadenectomy • Radiation necrosis
• MR
o End-to-end surgical anastomosis between corpus Clinical Issues
uteri and vaginal vault
o Posterior neofornix of vagina
• Normal post-trachelectomy appearance of pelvis on
MR should remain stable or improve with time
o Suture susceptibility artifacts
o Diffuse vaginal wall thickening
• Greatest risk of recurrence
o Original tumor size > 2 cm
o Engorgement of pelvic venous plexuses o Depth of invasion > 1 cm
• CT & US
• Successful pregnancy rates of between 40 and 70%
o Not helpful in demonstrating post-trachelectomy
appearances or early recurrent disease

MR shows the typical
trachelectomy appearance
with absence of the cervix and
an end-to-end uterovaginal
anastomosis . Note the
posterior vaginal neofornix
seen in ~ 50% of patients.
(Right) Axial T2WI FSE
MR at the level of the
posterior vaginal neofornix
demonstrates how this normal
postoperative structure can,
on axial images, mimic a mass
and recurrent disease.

shows to best advantage
susceptibility artifact from
sutures at the anastomosis
and from the cerclage placed
to maintain competency
in future pregnancies.
(Right) Coronal T1WI C+ FS
MR again shows absence
of the cervix and suture
susceptibility artifact at
the uterovaginal anastomosis.
Note also the engorgement
of pelvic vasculature ,
seen in ~ 10%, and typically
asymptomatic.
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POST-TRACHELECTOMY APPEARANCES
Cervix
o MR with triplane T2WI and vaginal gel
TERMINOLOGY o IV contrast to help exclude recurrence
Definitions
• Resection of cervix with end-to-end anastomosis of DIFFERENTIAL DIAGNOSIS
uterine corpus and vagina
Recurrent Tumor
IMAGING • Recurrent disease in < 5%
• Similar SI to original tumor
General Features o Intermediate to high signal on T2
• Best diagnostic clue o Enhances on T1 C+
o Absence of cervix with uterovaginal anastomosis • Biopsy may be necessary to differentiate from
• Performed for early stage cervical carcinoma (≤ IB1) postoperative change
• Alternative to radical hysterectomy in women wishing
Radiation Necrosis
•
to preserve fertility
• History of pelvic irradiation
• Fluid-distended endometrial cavity in ~ 50%
Radical trachelectomy & bilateral lymphadenectomy
o Resection of vaginal cuff, cervix, and parametria
▪ Preferably leave 1 cm of proximal endocervix • High signal on T2 with variable enhancement
o End-to-end anastomosis of vagina and corpus uteri • Increase in SI of bone marrow in irradiated field
o Cerclage suture for competence in future pregnancy
• Higher rate of complications with abdominal (ART) vs. CLINICAL ISSUES
vaginal (VRT) radical trachelectomy
o ART allows for removal of wider segment of Presentation
parametrial tissue
o ART is increasingly used for tumors ≤ 4 cm in size, < 1
• Initial eligibility criteria slowly becoming less stringent
o Tumor size ≤ 2 cm
cm from internal os, and > 50% stromal invasion o At least 1 cm between tumor and internal os
o < 50% cervical stromal invasion
MR Findings
o No parametrial invasion
• Normal postoperative appearances o No adenopathy
o End-to-end surgical anastomosis between corpus
uteri and vaginal vault • 17% of trachelectomies are abandoned intraoperatively
o Posterior neofornix of vagina (50%) due to unexpected findings
o Preoperative MR can be helpful
▪ Posterior extension of vaginal wall at uterovaginal o MR can accurately depict tumor size
anastomosis in sagittal plane o MR is able to predict tumor extension to internal os;
▪ Mass-like appearance in axial plane
sensitivity 90%, specificity 98%
▪ Appearances remain stable with time o High NPV of MR for parametrial invasion (94-100%)
o Suture susceptibility artifacts (20%)
▪ Due to anastomotic sutures and cerclage suture Natural History & Prognosis
▪ Artifact more pronounced on T1WI
o Diffuse vaginal wall thickening (5-10%)
• Risk factors for recurrence
o Tumor size > 2 cm
▪ Presumably related to parametrial dissection, o Depth of invasion > 1 cm
gradually resolves by 1 year o Lymphovascular space involvement
▪ Can mimic infiltrative tumor recurrence o Unfavorable histology
▪ Biopsy may be needed to exclude recurrence
o Engorgement of pelvic venous plexuses (10%)
• Overall death rate: 2.8%; 97% 5-year survival rate
▪ Irreversible
• Recurrence and death rates comparable to classical
radical abdominal hysterectomy
▪ Usually asymptomatic
• Postoperative complications
• Successful pregnancy rates between 40-70% reported
o 13% 1st trimester miscarriage rate
o Isthmic stenosis (2%) o 19% 2nd trimester miscarriage rate
▪ Dilation of endometrial cavity with fluid & blood o ↑ risk of preterm delivery; ~ 60% deliver > 37 weeks
▪ Presents with postsurgical amenorrhea
▪ Occurs as early as 3 months postoperatively
o Vaginal wall hematoma (5%) DIAGNOSTIC CHECKLIST
▪ ↑ SI collection on T2WI and T1WI FS
▪ Resolves slowly
o Lymphoceles (25%) • Absent cervix with end-to-end uterovaginal
▪ Appear as uni-/bilateral fluid collections in anastomosis with suture susceptibility artifacts
obturator or iliac distributions
▪ Can persist for several years SELECTED REFERENCES
o Hydrosalpinx (18% in 1 study)
1. Bourgioti C et al: MRI findings before and after abdominal
▪ Fluid-filled dilation of fallopian tubes radical trachelectomy (ART) for cervical cancer: a
▪ Concerning for affect on future fertility prospective study and review of the literature. Clin Radiol.
69(7):678-86, 2014
2. Sahdev A et al: MR imaging appearances of the female pelvis
after trachelectomy. Radiographics. 25(1):41-52, 2005
3
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Key Facts
• Benign proliferation of endocervical mucosal • Cervical adenocarcinoma
glandular elements • Nabothian cysts
Imaging • Other pseudoneoplastic glandular lesions
• Often undetectable on imaging, paucity of data • Cervical pregnancy
• Thickening of endocervical mucosa ± cystic change • Cervical stenosis
o Superficial (inner) layer of cervix Pathology
o May have homogeneous appearance
o Heterogeneity due to cystic change • Lobular endocervical glandular hyperplasia with
atypical cytologic features may be associated with
o Well-defined border with cervical stroma
adenoma malignum
• T1: Diffuse intermediate SI, ↑ SI cysts if high mucin
content Clinical Issues
• T2: May have thickening of mucosal layer, which • Most often asymptomatic
maintains normal hyperintensity • May be associated with abnormal vaginal bleeding or
• Small, simple, round, thin-walled cysts of ↑ T2 SI may vaginal discharge
coexist with mucosal thickening • Women of reproductive age, less commonly
• US: Thickened hyperechoic endocervical mucosa postmenopausal women

shows thickening of the
hyperintense inner layer
of cervical epithelium
compatible with glandular
hyperplasia. The endocervical
canal is highest in signal
intensity on T2WI due to
mucus and secretions. (Right)
Axial oblique T2WI FSE MR
the well-defined boundary
between the high-signal
thickened superficial epithelial
layer and low-signal inner
cervical stroma .

mild hyperintensity of the
thickening endocervical
lining due to high mucin
content. (Right) Sagittal T1WI
C+ FS MR shows relative
hypoenhancement of the
thickened mucosal layer
of the cervix. The lack
of solid components on
postcontrast images and
well-defined margin with the
cervical stroma on T2WI are
typical of cervical glandular
hyperplasia and help to
exclude malignancy.
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CERVICAL GLANDULAR HYPERPLASIA
Cervix
Definitions Cervical Adenocarcinoma
• Benign proliferation of endocervical mucosal glandular • Early stage can look like cervical gland hyperplasia
elements • Stromal invasion and deep location of cystic lesions are
suspicious for adenocarcinoma/adenoma malignum
IMAGING • Ill-defined margins with adjacent stroma favor
neoplasm
General Features Nabothian Cysts
• Best diagnostic clue • Superficial cystic structures usually seen at
o Often undetectable on imaging
squamocolumnar transition zone
o Thickening of endocervical mucosa ± cystic change
• Location
• Tend to be more focal and sparse, whereas hyperplasia
is more diffuse and regular
o Superficial (inner) layer of cervix
• Morphology Other Pseudoneoplastic Glandular Lesions
o May appear homogeneous ("solid" component) • No specific imaging criteria
o Heterogeneity due to cystic change • Endocervical mucosa may appear normal or present as
o Well-defined border with cervical stroma thickening
• Paucity of data in imaging literature • These include
o Reported cases are biased toward lesions with atypical o Papillary endocervicitis
imaging features mimicking adenoma malignum o Tunnel clusters
o Cervical endometriosis
CT Findings o Arias-Stella reaction
• CECT o Infectious processes
o Usually no significant abnormality o Reactive atypias
o If associated with cystic change, may show
hypodense foci Cervical Pregnancy
• Gestational sac distending endocervical canal
MR Findings • Usually excentrically located
• T1WI • Yolk sac or embryonic pole ± cardiac activity may be
o Cervix of diffuse intermediate signal intensity (SI) identified
o If associated with cystic change, low SI lesions in
superficial layer of cervix Cervical Stenosis
▪ Cysts may be hyperintense if high mucin content • Distension of cervical lumen with fluid
• T2WI o Fluid may be simple or complex (hematometra)
o Often no abnormality of endocervical mucosa • No mucosal thickening
o May manifest as thickening of mucosal layer
▪ Maintains normal hyperintense SI
▪ Small, round cysts of high SI may coexist with
PATHOLOGY
mucosal thickening General Features
• T1WI C+ FS • Associated abnormalities
o Enhancement pattern ranges from normal to o Lobular endocervical glandular hyperplasia with
hypovascular atypical cytologic features may be associated with
o No enhancement of cysts if present adenoma malignum
▪ Thin walls, absence of mural nodules
Ultrasonographic Findings • Often no visible abnormality
• Grayscale ultrasound • Some subtypes may be associated with erosions of
o Thickened hyperechoic mucosal layer of endocervix friable polypoid lesions
o If present, cysts are small, thin-walled, and anechoic
with posterior acoustic enhancement Microscopic Features
• Diffuse laminar endocervical glandular hyperplasia
o Proliferation of moderately sized, evenly spaced,
• Best imaging tool endocervical glands within inner 1/3 of cervical wall
o MR is imaging modality of choice to demonstrate o Discrete layer sharply demarcated from underlying
homogeneous mucosal thickening and lack of cervical stroma
stromal or deep involvement o Reactive cytologic atypia may be present, which is
• Protocol advice not significant
o Sagittal T2WI offers best depiction of cervical zonal • Hyperplasia of mesonephric remnants
anatomy o Main mesonephric duct surrounded by variable
o Dynamic T1 C+ FS images exclude wall thickening or number of small, round, and occasionally cystically
mural nodules when cystic changes are present dilated tubules
o Lined by nonmucinous cuboidal cells
o May develop florid hyperplasia
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Cervix CERVICAL GLANDULAR HYPERPLASIA
o No associated stromal reaction

• Glandular hyperplasia (not otherwise specified)
o Hyperplasia of endocervical epithelium, sometimes Consider
florid • Consider cervical gland hyperplasia in setting of
o Lack of deep invasion homogeneously thickened endocervical mucosa ±
o Well-demarcated margin with adjacent cervical cystic change
stroma • To differentiate from adenoma malignum, assess for
o Lobular grouping deeply seated cysts with complex features
o Lack of stromal reaction
o Bland nuclear features indicate absence of neoplasia Image Interpretation Pearls
• Microglandular hyperplasia • Thickened endocervical mucosa ± superficial cysts
o Closely packed glands showing thin walls and absence of mural nodules
▪ Lined by columnar, cuboidal, or flat cells
o Range from small and round to large, irregular, and SELECTED REFERENCES
cystically dilated 1. Takatsu A et al: Preoperative differential diagnosis
o Basophilic or eosinophilic reaction that stains for of minimal deviation adenocarcinoma and lobular
mucin endocervical glandular hyperplasia of the uterine cervix:
o Many acute inflammatory cells a multicenter study of clinicopathology and magnetic
o Stroma is occasionally hyalinized resonance imaging findings. Int J Gynecol Cancer.
• Florid endocervical glandular hyperplasia with 21(7):1287-96, 2011
2. Takeuchi K et al: Possible relationship between chronic
intestinal or pyloric gland metaplasia
o Proliferating endocervical glands surrounded by inflammation and pyloric metaplasia in a patient with
lobular endocervical glandular hyperplasia. Eur J Gynaecol
clusters of smaller glands resembling pyloric glands Oncol. 30(6):707-10, 2009
of stomach 3. Sugiyama K et al: MR findings of pseudoneoplastic lesions
o Occasional intestinal metaplasia in the uterine cervix mimicking adenoma malignum. Br J
o Bland nuclear features Radiol. 80(959):878-83, 2007
o Predominantly PAS(+) neutral mucin in glandular 4. Oguri H et al: MRI of endocervical glandular disorders:
epithelium three cases of a deep nabothian cyst and three cases of a
• All glands lined by single layer of columnar mucin- minimal-deviation adenocarcinoma. Magn Reson Imaging.
22(9):1333-7, 2004
secreting epithelium, except for hyperplasia of 5. Okamoto Y et al: Pelvic imaging: multicystic uterine cervical
mesonephric remnants lesions. Can magnetic resonance imaging differentiate
benignancy from malignancy? Acta Radiol. 45(1):102-8,
2004
CLINICAL ISSUES 6. Okamoto Y et al: MR imaging of the uterine cervix: imaging-
Presentation pathologic correlation. Radiographics. 23(2):425-45; quiz
• Most common signs/symptoms 534-5, 2003

7. Mikami Y et al: Lobular endocervical glandular hyperplasia
o Most often asymptomatic is a metaplastic process with a pyloric gland phenotype.
o May be associated with abnormal vaginal bleeding or Histopathology. 39(4):364-72, 2001
vaginal discharge 8. Yoden E et al: Florid endocervical glandular hyperplasia
with pyloric gland metaplasia: a radiologic pitfall. J Comput
Demographics Assist Tomogr. 25(1):94-7, 2001
• Age 9. Itoh K et al: A comparative analysis of cross sectional
o Women of reproductive age, less commonly imaging techniques in minimal deviation adenocarcinoma
postmenopausal women of the uterine cervix. BJOG. 107(9):1158-63, 2000
• Epidemiology
10. Mikami Y et al: Florid endocervical glandular hyperplasia
with intestinal and pyloric gland metaplasia: worrisome
o Very common, especially in women of reproductive benign mimic of "adenoma malignum". Gynecol Oncol.
age 74(3):504-11, 1999
▪ Oral contraceptive pill (progesterone stimulation) 11. Nucci MR et al: Lobular endocervical glandular hyperplasia,
▪ Pregnancy (microglandular hyperplasia) not otherwise specified: a clinicopathologic analysis of
thirteen cases of a distinctive pseudoneoplastic lesion and
Natural History & Prognosis comparison with fourteen cases of adenoma malignum. Am
• Often incidentally discovered on hysterectomy or cone J Surg Pathol. 23(8):886-91, 1999
biopsy specimen 12. Young RH et al: Pseudoneoplastic glandular lesions of the
• May be diagnosed during work-up of a multicystic uterine cervix. Semin Diagn Pathol. 8(4):234-49, 1991
cervical mass
• Usually not identified on Pap test
Treatment
• No treatment required
• Hysterectomy performed when adenoma malignum or
other aggressive lesion cannot be excluded
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CERVICAL GLANDULAR HYPERPLASIA
Cervix
hyperintense inner epithelial
layer of the cervix. Note
the diffuse involvement of the
cervix and preservation of zonal
anatomy typically seen with
cervical glandular hyperplasia.
MR short-axis view of the cervix
in the same patient shows to
best advantage the well-defined
boundary between the thickened
epithelial layer and the low-
signal fibrous stroma .

ultrasound shows that the
cervix is enlarged with
multiple hypoechoic lesions
Doppler ultrasound shows no
blood flow within the cervical
lesions as well as posterior
acoustic enhancement .
This sonographic appearance
is nonspecific with nabothian
cysts, cervical glandular
hyperplasia, and malignancy
such as adenoma malignum in
the differential diagnosis.
(Left) Sagittal T2WI FSE MR in

the same patient shows diffuse
cystic thickening of the inner
layer of the cervix. Although
the cervix is enlarged, the well-
defined boundary with the
cervical stroma is maintained.
(Right) Sagittal T1WI MR in the
same patient shows much of
the epithelial layer of the
cervix is mildly hyperintense
due to the mucin content. The
patient was asymptomatic
and had biopsies negative for
malignancy. She was diagnosed
with endocervical hyperplasia
and remained sonographically
stable for 8 years.
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Cervix NABOTHIAN CYSTS
Key Facts
• Mucinous endocervical gland cysts due to obstruction • Adenoma malignum
by overgrowth of squamous epithelium at their neck • Squamous cell carcinoma of cervix
• Tunnel clusters: Complex multicystic dilation of • Cystic adnexal mass
endocervical glands
Pathology
Imaging
• Circumscribed, unilocular, superficial cysts of cervix • Form as a result of healing process of chronic cervicitis
• Typically simple and superficial but can be complex • Tunnel clusters thought to result from stimulatory
phenomenon during pregnancy
and invade deep into cervical stroma
• Most are a few mm in diameter Clinical Issues
• Round or oval, single or multiple, can be numerous • Usually asymptomatic
• CT: Nonenhancing hypodense cervical lesion • Tunnel clusters almost always occur in multigravid
• T1: Intermediate to hyperintense to cervix women > 30 years of age
• T2: Hyperintense, circumscribed, superficial cervical • Great majority require no treatment
lesion
• US: Anechoic, circumscribed lesion with posterior
acoustic enhancement

FSE MR shows an oval,
circumscribed hyperintense
cyst located superficially
in the endocervical canal .
Note preservation of the low
signal cervical stroma .
shows the superficial location
of the cervical cyst in this
short-axis view of the cervix.
The intact cervical stroma
is seen well in this plane.
The oval shape, smooth walls,
and superficial location are
typical of an uncomplicated
nabothian cyst.
(Left) Longitudinal
of the uterus and cervix
shows multiple oval,
circumscribed, anechoic
lesions with posterior
acoustic enhancement in
the cervix. The lesions have
smooth walls without mural
nodules or septations. (Right)
Longitudinal color Doppler
shows no internal blood flow
in these simple cysts . Note
the cysts' superficial location
relative to the endocervical
canal . These features are
characteristic of nabothian
3 cysts.
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NABOTHIAN CYSTS
Cervix
TERMINOLOGY ▪ Well defined
▪ Anechoic with posterior acoustic enhancement
Synonyms ▪ Along epithelial surface of endocervical canal or
• Endocervical gland cysts ectocervix
• Retention cysts of cervix o Mucinous contents may be hypoechoic or contain
• Tunnel clusters debris
o Uncommonly, multicystic complex lesion
Definitions penetrating deep into cervical stroma
• Nabothian cysts and endocervical gland cysts • Color Doppler
o Mucinous endocervical gland cysts due to o No color flow
obstruction by overgrowth of squamous epithelium • Power Doppler
at their necks o Helps to differentiate deep nabothian cysts from
• Tunnel clusters more aggressive lesions
o Specific type of nabothian cyst characterized by o Nabothian cysts show no flow, whereas flow may
complex multicystic dilation of endocervical glands be seen within wall of cystic portion of adenoma
malignum
IMAGING Other Modality Findings
General Features • May have uptake on I-131 imaging for thyroid cancer
• Best diagnostic clue Imaging Recommendations
o Circumscribed, unilocular, superficial cysts of cervix • Best imaging tool
• Location o Best characterized on TVUS
o Occur along endocervical canal or ectocervix o MR may help exclude malignant mimics if TVUS is
o Typically superficial but can invade deep into cervical technically limited
stroma • Protocol advice
o Usually seen at colposcopic examination on surface o Power Doppler imaging may be useful for
of ectocervix distinguishing nabothian cysts from carcinoma
▪ Protrusions at squamocolumnar transition zone o Features that warrant further evaluation
• Size ▪ Large
o Most are a few mm in diameter ▪ Multiloculated
o May reach 4 cm on occasion ▪ Any solid elements within cysts
o Extensive cyst formation may result in enlargement • Vast majority are incidental and require no further
of cervix evaluation
• Morphology
o Round or oval
o Typically simple cystic lesion but can be complex
o Single or often multiple, can be numerous Adenoma Malignum
CT Findings • Low-grade mucinous carcinoma affecting deep
• NECT endocervical glands
• Forms multilocular cystic masses in cervix
o Isodense or hypodense to cervix
o Hyperdense to cervix if complicated • Enhancing solid components
• CECT • Deeply penetrating into cervical stroma
o Nonenhancing hypodense cervical lesion • Typical history of copious watery vaginal discharge
o Single rounded lesion or multicystic lesion Squamous Cell Carcinoma of Cervix
• When large and complex, may mimic endocervical
• Solid mass of cervix, not cystic
gland tumor
• May have areas of necrosis, but solid elements
MR Findings predominate
• T1WI Cystic Adnexal Mass
o Intermediate to hyperintense to cervix
▪ Hyperintensity due to mucinous contents
• Mass originates in adnexa, not cervix
• T2WI
• Nabothian cysts are in close proximity to vaginal probe
o Hyperintense, circumscribed, superficial cervical
lesions PATHOLOGY
o Less commonly complex multicystic lesions
General Features
• Etiology
penetrating deep into cervical stroma
• T1WI C+
o May be seen in postpartum cervix with ectropion
o Cysts do not enhance
o Form as a result of healing process of chronic
Ultrasonographic Findings cervicitis
• Grayscale ultrasound ▪ Squamous epithelium grows back over ectocervix
o Most commonly, simple superficial cystic cervical ▪ Underlying columnar cells of endocervical glands
lesion become obstructed
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Cervix NABOTHIAN CYSTS
▪ Columnar epithelium beneath squamous layer o Cryosurgery

continues to secrete mucus o Conization
▪ Trapped secretions result in dilation of gland with
cyst formation
o May be seen with patients on progestogenic therapy DIAGNOSTIC CHECKLIST
▪ Due to failure of cyclic flow of cervical mucus Consider
o Tunnel clusters thought to result from stimulatory
phenomenon during pregnancy
• Incidental simple cystic lesions located superficially
along cervical canal
Gross Pathologic & Surgical Features • Further evaluate for malignancy if
• Yellow or white cysts on surface of cervix o Complex with solid components
o Deep invasion of cervical stroma
• Frequently multiple o Copious vaginal discharge
• Size ranges from a few mm to 4 cm at colposcopy
• Tunnel clusters are only seen upon sectioning of cervix Image Interpretation Pearls
• Appear as rounded cysts filled with clear fluid • Well-defined, small, simple cervical cysts
Microscopic Features • Superficial location along cervical canal
• Cysts are lined by low columnar mucin-producing
epithelium SELECTED REFERENCES
• Tunnel clusters 1. Liu S et al: Nabothian cyst associated with high false-
o Lobular proliferation of small, tunnel-like extensions positive incidence of iodine-131 uptake in whole-body scans
of endocervical clefts after treatment for differentiated thyroid cancer. Nucl Med
o Thought to be unrelated to exogenous hormones or Commun. 34(12):1204-7, 2013
inflammation 2. Nigam A et al: Large nabothian cyst: a rare cause
o Theorized to follow hyperstimulatory state such as of nulliparous prolapse. Case Rep Obstet Gynecol.
2012:192526, 2012
pregnancy 3. Bin Park S et al: Multilocular cystic lesions in the uterine
o Type A
cervix: broad spectrum of imaging features and pathologic
▪ Nondilated, small caliber tunnels lined by tall, correlation. AJR Am J Roentgenol. 195(2):517-23, 2010
mucinous columnar epithelium 4. Sugiyama K et al: MR findings of pseudoneoplastic lesions
▪ Usually an incidental finding in the uterine cervix mimicking adenoma malignum. Br J
o Type B Radiol. 80(959):878-83, 2007
▪ Cystic tunnels lined by cuboidal to flattened cells 5. Oguri H et al: MRI of endocervical glandular disorders:
▪ Produce gross cystic abnormality three cases of a deep nabothian cyst and three cases of a
minimal-deviation adenocarcinoma. Magn Reson Imaging.
▪ More common compared to type A
22(9):1333-7, 2004
▪ Tends to occur in an older population 6. Okamoto Y et al: MR imaging of the uterine cervix: imaging-
▪ Thought to arise from type A due to obstruction pathologic correlation. Radiographics. 23(2):425-45; quiz
534-5, 2003
7. Li H et al: Markedly high signal intensity lesions in the
CLINICAL ISSUES uterine cervix on T2-weighted imaging: differentiation
between mucin-producing carcinomas and nabothian cysts.
Presentation
Radiat Med. 17(2):137-43, 1999
8. Pelosi MA 3rd et al: Symptomatic cervical macrocyst as a
o Usually asymptomatic late complication of subtotal hysterectomy. A case report. J
o Most commonly, incidental finding Reprod Med. 44(6):567-70, 1999
• Other signs/symptoms 9. Umesaki N et al: Power Doppler findings of adenoma
o Rarely may become infected malignum of uterine cervix. Gynecol Obstet Invest.
• Clinical profile 10.

45(3):213-6, 1998
Jones MA et al: Endocervical type A (noncystic) tunnel
o Tunnel clusters almost always occur in multigravid clusters with cytologic atypia. A report of 14 cases. Am J Surg
women > 30 years of age Pathol. 20(11):1312-8, 1996
▪ Often occur during pregnancy 11. Daya D et al: Florid deep glands of the uterine cervix.
• Must be differentiated from adenoma malignum Another mimic of adenoma malignum. Am J Clin Pathol.
103(5):614-7, 1995
Demographics 12. Yamashita Y et al: Adenoma malignum: MR appearances
• Epidemiology mimicking nabothian cysts. AJR Am J Roentgenol.
o Appear to increase in prevalence with increasing age 162(3):649-50, 1994
13. Togashi K et al: CT and MR demonstration of nabothian
o 8% of adult women
cysts mimicking a cystic adnexal mass. J Comput Assist
o 13% of postmenopausal women Tomogr. 11(6):1091-2, 1987
14. Fogel SR et al: Sonography of Nabothian cysts. AJR Am J
• Slow growing
Roentgenol. 138(5):927-30, 1982
Treatment
• Great majority require no treatment
• Cases of symptomatic, unremitting, chronic cervicitis
may benefit from
3 o Cyst drainage
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NABOTHIAN CYSTS
Cervix
(Left) Longitudinal
a pregnant patient shows a
complex cystic lesion in the
cervix . (Right) Transverse
power Doppler ultrasound in the
same patient demonstrates no
blood flow within the cervical
lesion or internal debris .
Note the posterior acoustic
enhancement . Cervical cysts
in pregnancy are thought to be
due to stimulatory phenomenon
and are more often complex.

shows multiple hyperintense
lesions in the cervix
penetrating deep into the stroma
. (Right) Coronal oblique
T2WI FSE MR through the cervix
shows the relationship of the
cystic lesions to the cervical
canal and epithelium to best
advantage.

oval, smooth-walled cysts
without mural nodules,
which is compatible with deep
nabothian cysts. Although
typically superficial, nabothian
cysts can penetrate deep into
the cervical stroma. However,
they usually maintain their
simple cystic appearance and
are asymptomatic. (Right) Axial
shows the cervical cysts are
hypointense, further confirming
their simple fluid contents.
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SECTION 4
Vagina and Vulva

Vaginal and Vulvar Anatomy 4-2
Congenital
Vaginal Atresia 4-10
Imperforate Hymen 4-14
Vaginal Septa 4-16
Benign Neoplasms
Vaginal Leiomyoma 4-18
Vulvar Hemangioma 4-24
Vaginal Paraganglioma 4-28
Malignant Neoplasms
Vaginal Carcinoma 4-32
Vaginal Leiomyosarcoma 4-44
Embryonal Rhabdomyosarcoma 4-46
Vaginal Yolk Sac Tumor 4-50
Bartholin Gland Carcinoma 4-54
Vulvar Carcinoma 4-56
Vulvar Leiomyosarcoma 4-70
Vulvar and Vaginal Melanoma 4-72
Aggressive Angiomyxoma 4-76
Merkel Cell Tumor 4-80
Lower Genital Cysts

Gartner Duct Cysts 4-82
Bartholin Cysts 4-86
Bartholinitis 4-90
Urethral Diverticulum 4-94
Skene Gland Cyst 4-98
Miscellaneous
Vaginal Foreign Bodies 4-102
Vaginal Fistula 4-110
Obgyne Books Full

Vagina and Vulva VAGINAL AND VULVAR ANATOMY
• Innervation
TERMINOLOGY ◦ Via sacral plexus (S2-5)
Synonyms • Structural support
• ◦ Upper vagina supported by cardinal, uterosacral, and
Pudenda (vulva)
pubocervical ligaments; support also provided by
Definitions rectovaginal fascia
• Vagina (Latin for sheath): Fibromuscular tube with ◦ Middle vagina supported by urogenital diaphragm,
mucosal lining that extends from vulva to cervix endopelvic fascia, and levator ani muscular complex
• Vulva (Latin for covering): Female external genitalia ◦ Lower vagina supported by perineal body
extending from symphysis pubis anteriorly to perineum attachments
posteriorly, medial to inguinal/gluteal folds • Histology
◦ Inner mucosal lining
GROSS ANATOMY ▪ Lined by stratified squamous epithelial cells,
similar to those found on ectocervix
Vagina ▪ Rare melanocytes and Langerhans cells
• Positioning ▪ Thickness of epithelial layer is estrogen sensitive,
◦ Near-vertical orientation: ~ 60° of angulation
slightly increasing in thickness at ovulation and
between vaginal axis and vestibule thinned/atrophied without estrogen
◦ Interposed between bladder/urethra and rectum
▪ Underlying stromal layer is rich in elastic tissues
▪ Separated from bladder/urethra by connective
and lymphovascular structures
tissue (vesicovaginal septum) ▪ No vaginal glands; vaginal moisture is maintained
▪ Separated from rectum by rectovaginal septum
by cervical and Bartholin gland secretions
◦ Upper portion of posterior vagina is covered by a
◦ Middle muscular layer
reflection of peritoneum, forming rectouterine pouch ▪ Inner layer composed of circular muscular fibers
(of Douglas) ▪ Outer layer composed of longitudinal muscle fibers
◦ Upper vagina lies above pelvic floor whereas lower
◦ Outer adventitial layer composed of endopelvic fascia
vagina resides within perineal space and helps to provide support
◦ Located in middle compartment of pelvis
◦ Adenosis (gland-like structures lined by endocervical-
• Morphology type cells) may be present
◦ Anterior and posterior walls are typically in close
▪ Secondary to abnormal cellular differentiation
approximation, with lateral walls more lax during embryogenesis
▪ Results in classic "H" morphology on axial imaging
▪ Increased prevalence with DES exposure
◦ Upper vagina folds around cervix to form recessed
◦ Rarely, mesonephric (wolffian) ductal element
vaginal fornices remnants may be present
▪ Posterior fornix is typically larger due to uterine
anteversion Vulva
◦ Prominent longitudinal folds project into vaginal • External female genitalia within superficial perineal
lumen from anterior and posterior walls pouch, in anterior urogenital triangle
◦ Mucosal surface has small transverse ridges (rugae) in • Composed of
nulliparous women ◦ Mons pubis
▪ Not present after childbirth or menopause ▪ Fatty swelling overlying pubic symphysis
◦ Vagina divided into thirds ◦ Labia majora
▪ Upper 1/3: At level of vaginal fornices ▪ Lateral skin folds and underlying fat that converge
▪ Middle 1/3: At level of bladder base anteriorly/superiorly at mons pubis
▪ Lower 1/3: Below bladder base, at level of urethra ▪ Become less prominent after childbirth and
• Size: Typically 4-12 cm in length menopause
◦ Anterior wall is usually shorter: 4-8 cm ▪ Round ligament ends at upper labia majora
◦ Posterior wall is usually longer: 8-10 cm ◦ Labia minora
• Arterial supply ▪ Small folds of skin medial to labia majora, 3-4 cm in
◦ Complex vascular supply with contributions from length
branches if internal iliac artery ▪ Fuse anteriorly/superiorly to form clitoral frenulum
▪ Descending cervicovaginal artery (upper 1/3 of and prepuce
vagina) ▪ Fuse inferiorly/posteriorly to form posterior
▪ Inferior vesicular artery (middle 1/3 of vagina) fourchette
▪ Middle rectal/inferior pudendal arteries (lower 1/3 ▪ Contain sebaceous glands
of vagina) ◦ Clitoris and erectile apparatus
• Venous drainage ▪ Cylindrical nodule at anterior vestibule that
◦ Perivaginal venous plexus drains parallel to arterial contains erectile tissue
supply into internal iliac system ▪ Enlarges with sexual arousal
• Lymphatic drainage ▪ 0.5 -1 cm in diameter, < 2 cm in length
◦ Upper vagina: Internal and external iliac nodes ▪ Composed of glans, corpus, and paired crura
(similar to cervical drainage pattern) ▪ Crura extend posteriorly and laterally along
◦ Middle vagina: Internal iliac nodes inferior pubic rami
◦ Lower vagina: Superficial inguinal nodes (similar to
4 vulvar drainage pattern)
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VAGINAL AND VULVAR ANATOMY
Vagina and Vulva

▪ Vestibular bulbs are oval collections of paravaginal • Distal vaginal wall is essentially fused with posterior
erectile tissue fused superiorly that lie along lateral urethral wall
margins of vestibule • MR
◦ External urethral meatus ◦ Mucosal layer
▪ Inferior/posterior to clitoris ▪ T2 hyperintense; may be thicker and more
▪ 0.5 cm in diameter hyperintense in late proliferative phase, early to
▪ Paired Skene gland ducts empty along mid secretory phase, and during pregnancy
posterolateral external urethral meatus ▪ T1 hypointense
◦ Vestibule ▪ Smooth enhancement on T1 C+ FS imaging
▪ Medial to labia minora ◦ Submucosal and muscular layers
▪ Extends from clitoris anteriorly to posterior ▪ Hypointense on T2- and T1-weighted imaging
fourchette ◦ Endoluminal secretions appear T2 hyperintense and
▪ Contains vaginal introitus, external urethral T1 hypointense
meatus, hymen, and Bartholin duct orifices (along ◦ Surrounding vaginal venous plexus may appear
posterolateral vestibule) hyperintense on T2WI due to slow flow
◦ Posterior fourchette • CT
▪ Point of posterior/inferior fusion of labia minora ◦ Thin walls
• Arterial supply ▪ Mucosa may show prominent smooth, early
◦ Predominantly through branches of external/ enhancement in premenopausal patients; usually
internal pudendal and middle rectal arteries hypoenhancing in postmenopausal women
• Venous drainage ▪ Muscular layer is hypoattenuating when compared
◦ Parallels arterial supply, draining into iliac system to mucosa
• Lymphatic drainage ◦ May be difficult to distinguish from other soft tissue
◦ Primarily to superficial inguinal nodes pelvic structures when little pelvic fat
• Innervation • US
◦ Via branches of pudendal nerve (S2-4) ◦ Vaginal wall is best evaluated on transvaginal
▪ Also receives contributions from genitofemoral imaging
(L1-2), ilioinguinal (L1), and iliohypogastric (T12- ▪ Wall evaluation can be performed as endovaginal
L1) nerves probe is inserted
◦ Anterior/superior vulva may be innervated by ◦ Distal vagina/introitus can be evaluated with
branches of ilioinguinal and genitofemoral nerves transperineal/translabial imaging
• Histology ◦ Vaginal walls appear hypoechoic and uniformly thin
◦ Majority of vulva is covered by keratinized stratified ◦ Coapted vaginal mucosal layers appear as echogenic
squamous cell layer linear interface
▪ May contain melanocytes, Langerhans and Merkel
cells
Vulva
• Triangular region of soft tissue within superficial
◦ Vestibule is covered by a nonkeratinized stratified
squamous cell layer perineal space
• Imaging landmarks include
◦ Skene glands
◦ Pubic symphysis anteriorly
▪ Lined by mucin-producing columnar epithelium
◦ Perineal body posteriorly
▪ Ducts lined by transitional epithelium
◦ Ischial tuberosities laterally
◦ Bartholin glands
• MR
▪ Composed of acini lined by columnar epithelium
◦ General signal intensity of vulvar soft tissues
▪ Ducts lined by columnar, transitional, and
▪ T1 hypointense to intermediate signal
squamous epithelium
▪ T2 slightly hyperintense signal
◦ Numerous minor vestibular glands drain directly into
◦ Distal urethra will demonstrate typical layered/
vestibule, lined by mucin-producing epithelium
targetoid appearance
▪ Oriented near vertical, extending from bladder
IMAGING ANATOMY
base to anterior vestibule
Overview ◦ Clitoral erectile tissues and vestibular bulbs may
• MR is preferred modality owing to superior soft tissue appear T2 hyperintense
differentiation • CT
◦ Allows for delineation of vulvar anatomy ◦ Vulva is of soft tissue attenuation
◦ Superior evaluation of vaginal wall and ◦ May be difficult to differentiate specific structures
characterization of associated lesions within vulva
• CT is most useful in staging of vaginal/vulvar • US: Vulva can be evaluated with superficial US
malignancy
◦ Evaluation for nodal and metastatic disease ANATOMY IMAGING ISSUES
◦ Not as accurate as MR in evaluation of extent of local
tumor
• MR
Vagina ◦ Preferred imaging modality for local tumor
• Typically decompressed, producing a "H" or "U" evaluation/staging as well as lesion characterization
morphology on axial imaging 4
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◦ Typically imaged with pelvic phased-array surface

coil
EMBRYOLOGY
◦ Endoluminal (endovaginal) coils can be used for Embryologic Events
high-resolution imaging of vagina • Vaginal embryology
▪ Limited field of view; remainder of pelvis may not ◦ Upper vagina arises from caudal aspect of fused
be adequately evaluated müllerian (paramesonephric) ducts
◦ Endovaginal contrast (water-soluble US gel or surgical ◦ Lower vagina arises from urogenital sinus
lubricant) is essential when vaginal evaluation is ◦ By 7th week of gestation, müllerian ducts begin to
necessary fuse with urogenital sinus
▪ Distends lumen to allow for better evaluation of
◦ Rudimentary vagina is present by 10th week
walls ◦ Vagina becomes lined by squamous cells by 11th
• CT week
◦ Due to nonspecific soft tissue attenuation of
▪ Will proliferate to eventually fill rudimentary
decompressed vagina and vulva, CT is of limited use vaginal lumen
in characterizing vaginal and vulvar lesions ▪ Estrogen receptors become present within vaginal
◦ CT is valuable in detection of lymphadenopathy and
wall
distant metastatic disease for staging of vaginal and ◦ Secondary vaginal cavitation begins by 16th week
vulvar malignancies ◦ Vaginal development is complete by 5th month
◦ Endovaginal contrast (water-soluble ultrasound gel or
• Vulvar embryology
surgical lubricant) can be used to distend vagina and ◦ By 4-6th week of gestation, external genitalia begins
better evaluate vaginal walls/mucosa to develop with formation of genital tubercle,
▪ Can be helpful to evaluate vagina in patients who
urogenital membrane, paired urogenital folds, and
cannot undergo MR evaluation paired genital swellings
• US ◦ 7th week of gestation
◦ Vaginal evaluation is best performed with
▪ Urogenital folds and genital swellings fuse
endovaginal probe anteriorly to form mons pubis
▪ Transabdominal technique may be helpful
▪ Fuse posteriorly to form posterior fourchette and
▪ Translabial/perineal techniques can evaluate distal
perineum
vagina/introitus ▪ Urogenital membrane regresses to expose
◦ Superficial US can be used to evaluate vulva
urogenital sinus lumen
◦ Between 10th and 20th weeks
CLINICAL IMPLICATIONS ▪ Genital tubercle develops into clitoris
▪ Urogenital sinus develops into vestibule (including
Clinical Importance
• Vagina is very pliable and elastic hymeneal membrane and introitus) and lower
◦ Allows for increased caliber during intercourse and vagina
▪ Urogenital folds form labia minora
childbirth
▪ Labial swellings form labia majora
• Vaginal pathologies include
◦ Inflammatory
▪ Vaginal fistula RELATED REFERENCES
◦ Neoplasm
1. Bitti GT et al: Pelvic floor failure: MR imaging evaluation
▪ Benign leiomyoma
of anatomic and functional abnormalities. Radiographics.
▪ Primary vaginal carcinoma 34(2):429-48, 2014
▪ Metastatic disease (including extension from 2. Ventolini G: Vulvar pain: Anatomic and recent
adjacent organs) pathophysiologic considerations. Clin Anat. 26(1):130-3,
◦ Congenital/developmental 2013
▪ Vaginal septation (± hydrometrocolpos) 3. Hosseinzadeh K et al: Imaging of the female perineum in
▪ Vaginal agenesis/hypoplasia adults. Radiographics. 32(4):E129-68, 2012
4. Laterza RM et al: Female pelvic congenital malformations.
▪ Gartner duct cysts
Part I: embryology, anatomy and surgical treatment. Eur J
• Vulva can be affected by a variety of pathologies Obstet Gynecol Reprod Biol. 159(1):26-34, 2011
◦ Inflammatory 5. Grant LA et al: Congenital and acquired conditions of
▪ Bartholin gland cyst/abscess the vulva and vagina on magnetic resonance imaging: a
▪ Skene gland cyst pictorial review. Semin Ultrasound CT MR. 31(5):347-62,
▪ Infection (soft tissue abscess, Fournier gangrene) 2010
▪ Labial thrombophlebitis 6. Parikh JH et al: MR imaging features of vaginal
◦ Neoplasm malignancies. Radiographics. 28(1):49-63; quiz 322, 2008
7. Cunningham FG: Williams Obstetrics. 22nd ed. New York:
▪ Primary vulvar carcinoma
McGraw-Hill, Medical Publishing Division, 2005
▪ Metastatic disease/lymphoma
8. Ferris DG: Modern Colposcopy. 2nd ed. Dubuque, IA:
◦ Congenital/developmental Kendall/Hunt Publishing Company, 2004
▪ Vascular malformations 9. Siegelman ES et al: High-resolution MR imaging of the
▪ Hydrocele of canal of Nuck vagina. Radiographics. 17(5):1183-203, 1997
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Uterine cervix

Anterior vaginal fornix
Urinary bladder Rectum
Vaginal adventitia
Vaginal mucosa
Urethra Vaginal muscular layer
Anus
Vaginal introitus
Mons pubis
Labia majora
Clitoris
External urethral meatus

Vestibule
Labia minora
Vaginal introitus
Anus
Posterior fourchette
(Top) Sagittal illustration shows the anatomic relationships of the vagina to other pelvic organs. The vagina is typically decompressed and
positioned between the bladder and urethra anteriorly and the rectum posteriorly. Note the transverse mucosal folds (vaginal rugae), which are
commonly seen in nulliparous women. (Bottom) Illustration shows the female external genitalia that encompass the vulva.
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VAGINAL ANATOMY: AXIAL MR
Pubic symphysis
Hyperintense vaginal
mucosa
Urethra
Paravaginal venous plexus

Hypointense vaginal wall
muscle layer
Pubic symphysis
Urethra
Anus
Vagina
(Top) Axial T2WI FS MR demonstrates normal vaginal anatomy. The vagina is decompressed and has a classic "H" morphology. The vaginal
mucosa is hyperintense and can increase in thickness and intensity under higher levels of estrogen. The muscular layer of the vaginal wall is
thin and hypointense. Note the relationship of the vagina to the urethra. The paravaginal venous plexus typically appears hyperintense due to
slow flow. (Bottom) Axial T1WI C+ FS MR through the inferior pelvis shows the normal appearance of the vagina. The vagina is decompressed,
with the anterior and posterior walls closely apposed; this produces the classic "H" or "U" morphology seen on axial imaging. Note the intense
enhancement of the vaginal mucosa.
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VAGINAL ANATOMY: CT AND US
Urethra
Pubic symphysis
Vagina
Anus
Urinary bladder
Hypoechoic vaginal walls
Echogenic coapted vaginal

mucosal layers
(Top) Axial CECT demonstrates the normal appearance of the vagina. The mucosa is avidly enhanced, best seen on earlier phases of contrast
administration. The vagina is decompressed and has a classic "H" morphology. Note the relationship of the vagina with adjacent pelvic
structures. (Bottom) Transverse transabdominal US of the pelvis demonstrates a normal appearance of the decompressed vagina. The vaginal
walls appear hypoechoic whereas the coapted vaginal mucosal layers produce a central bright linear echo. While the vagina is routinely imaged
on transabdominal pelvic sonography, US evaluation of the vaginal wall is best performed with a transvaginal technique.
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VAGINAL ANATOMY: SAGITTAL MR
Uterine fundus
Air bubbles
Urethra Vaginal lumen distended

with gel
Skene gland cyst
Enhancing myometrium
Anterior vaginal fornix
Vaginal wall
Urethra
(Top) Sagittal T2WI MR through the pelvis shows the vagina and adjacent organs. The vagina is distended with contrast material (water-soluble
US gel or surgical lubricant) allowing for better evaluation of the thin vaginal wall. Note how the posterior urethral wall and anterior vaginal wall
are essentially fused. (Bottom) Sagittal T1WI C+ FS MR shows a normal appearance of the vagina. The vaginal wall should show smooth, thin,
linear enhancement and is best evaluated when the vagina is distended with contrast material (water-soluble US gel or surgical lubricant).
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VULVAR ANATOMY: MR, CT, AND US
Clitoris
Right crus of clitoris Left crus of clitoris
Anus
Vaginal introitus
Clitoris
Right crus of clitoris Enhancing distal vaginal mucosa
Anus
Clitoral body/glans Vaginal introitus
Decompressed vagina
Urethra
Echogenic coapted vaginal mucosal
layers
Hypoechoic vaginal wall muscular

layer
Bladder
(Top) Axial T2WI MR through the inferior pelvis shows normal vulvar anatomy. The body and glans of the clitoris are seen anteriorly, with the
2 clitoral crura posteriorly. The external urethral meatus and vaginal introitus are more posterior/inferior. (Middle) Axial CECT shows normal
vulvar anatomy. As soft tissue differentiation is less pronounced than on MR imaging, vulvar anatomy can be difficult to delineate on routine CT
imaging. (Bottom) Longitudinal translabial US image shows the normal vulvar anatomy. US is not typically used in vulvar imaging; transperineal
and translabial US techniques are best suited for vulvar evaluation when indicated.
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Key Facts
Terminology • Transabdominal and transperineal ultrasound can be
• Failure of primitive urogenital sinus to develop (which used as initial imaging modality
• Pelvic MR is modality of choice
gives rise to lower 1/3 of vagina)
• Absence of lower vagina with fibrotic tissue replacing • Transverse vaginal septum
lower 1/3 of vagina • Imperforate hymen
• Secondary hematometrocolpos • Vaginal agenesis with uterine hypoplasia
• Differs from vaginal agenesis as it is not a müllerian Clinical Issues
duct anomaly
• Normal uterus and upper 2/3 of vagina (müllerian • Usual presentation at menarche with primary
structures) amenorrhea and cyclic abdominopelvic pain
• Normal ovaries • Normal reproductive outcomes after correction
• Associated complications: Endometriosis • In patients with a dimple at introitus, long-term
• Vagina more distended than endometrial cavity dilation is a consideration
• Vaginoplasty is reserved for failed dilations
• Lower margin of vagina replaced by low signal
intensity fibrous tissue with loss of normal zonal
anatomy extending to introitus
(Left) Axial T2WI FSE MR of

the pelvis shows a rudimentary
midline T2 dark structure
representing an atretic
vagina in in a 14-year-old girl
with vaginal atresia. (Right)
Axial T2WI FSE MR lower
down in the pelvis in the same
patient shows shows absence
of the vagina in its expected
position (posterior to the
urinary bladder and anterior
to the rectum), consistent with
vaginal atresia.

centered low in the pelvis in
a child with vaginal atresia
shows absence of the normal
vaginal fornices in its
expected location posterior to
the urethra and anterior to the
rectum. (Right) Sagittal T2WI
FSE MR in a girl with vaginal
atresia shows absence of the
vagina in its normal expected
midline position , replaced
by a linear region of fat.
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Vagina and Vulva

o Isolated or in association with vertical vaginal septa
TERMINOLOGY
of müllerian duct anomalies
Definitions • Normal vaginal zonal anatomy preserved
• Failure of primitive urogenital sinus to develop (which Imperforate Hymen
• Distal vaginal obstruction associated with
gives rise to lower 1/3 of vagina)
hematometrocolpos
IMAGING • Normal uterus with preserved vaginal length
General Features Vaginal Agenesis With Uterine Hypoplasia
• Best diagnostic clue • Absent normal zonal anatomy of upper 2/3 of vagina
o Absence of lower vagina with fibrotic tissue replacing o Variable degree of upper vaginal distension if residual
lower 1/3 of vagina preserved segment
o Secondary hematometrocolpos • Lower vagina typically preserved
o Differs from vaginal agenesis as it is not a müllerian
duct anomaly
• Rudimentary uterus with distended endometrial cavity
o Normal uterus, upper 2/3 of vagina, and ovaries
PATHOLOGY
CT Findings
• Dilatation of vagina &/or endometrial cavity with fluid Gross Pathologic & Surgical Features
MR Findings
• Failure of canalization of urogenital sinus
• T1WI FS
o Dilatation of vagina and endometrial cavity with CLINICAL ISSUES
blood products (hematometrocolpos)
o Associated complications: Endometriosis
Presentation
• T2WI • Most common signs/symptoms
o Usual presentation at menarche with primary
o Dilatation of vagina &/or endometrial cavity with
amenorrhea and cyclic abdominopelvic pain
fluid o Progressive degree of hematometrocolpos depending
▪ Intraluminal fluid of intermediate or high signal
on time of diagnosis following menarche
intensity
▪ Occasionally fluid/debris levels Natural History & Prognosis
o Vagina more distended than endometrial cavity • Normal reproductive outcomes after correction
▪ Distention of endometrial cavity usually < 1.0 cm
o Lower margin of vagina replaced by low signal Treatment
intensity fibrous tissue with loss of normal zonal • In patients with a dimple at introitus, long-term
anatomy extending to introitus dilation is a consideration
• Vaginoplasty is reserved for failed dilations
• Distended, fluid-filled structure ending in blind pouch SELECTED REFERENCES
at lower margin of vagina
o Intraluminal fluid contents variable: Anechoic, 1. Singhal SR et al: Uterus didelphys with partial vaginal
hypoechoic with low-level echoes, or echogenic septum and distal vaginal agenesis: an unusual anomaly. J
o Vagina shows greater degree of distention than Coll Physicians Surg Pak. 23(2):149-51, 2013
endometrial cavity 2. Santos XM et al: The utility of ultrasound and magnetic
o Normal zonal anatomy of lower vagina replaced by resonance imaging versus surgery for the characterization
hypoechoic fibrous band of müllerian anomalies in the pediatric and adolescent
• Normal ovaries
3.
population. J Pediatr Adolesc Gynecol. 25(3):181-4, 2012
Sarathi V et al: Mucocolpos in a toddler: central precocious
Imaging Recommendations puberty with vaginal atresia. Endocr Pract. 18(6):e144-6,
• Best imaging tool 4.

2012
Laterza RM et al: Female pelvic congenital malformations.
o Transabdominal and transperineal ultrasound can be Part I: embryology, anatomy and surgical treatment. Eur J
used as initial imaging modality Obstet Gynecol Reprod Biol. 159(1):26-34, 2011
o Pelvic MR modality of choice 5. Walker DK et al: Overlooked diseases of the vagina: a
• Protocol advice directed anatomic-pathologic approach for imaging
o Phased-array body coil assessment. Radiographics. 31(6):1583-98, 2011
o High-resolution fast spin-echo (FSE) T2WI 6. Church DG et al: Magnetic resonance imaging for uterine
and vaginal anomalies. Curr Opin Obstet Gynecol.
▪ ≤ 4 mm slice thickness 21(5):379-89, 2009
▪ Axial and coronal/sagittal multiplanar imaging 7. Economy KE et al: A comparison of MRI and laparoscopy
o T1WI ± FS: Confirms presence of blood products in detecting pelvic structures in cases of vaginal agenesis. J
Pediatr Adolesc Gynecol. 15(2):101-4, 2002
Transverse Vaginal Septum
• Fibrous septum at junction of middle and upper 1/3 of
vagina with hematometrocolpos 4
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image of the pelvis shows
a large round cystic
structure containing low-
level internal echoes
with posterior acoustic
enhancement corresponding
to hematocolpos in this young
girl proven to have vaginal
atresia. (Right) Longitudinal
ultrasound image of the pelvis
in the same girl with vaginal
atresia shows the marked
distension of the vaginal cavity
with blood products.

image of the pelvis shows
hematometrocolpos, with
greater distension of the
vaginal cavity relative
to the endometrial cavity
in this girl with vaginal
atresia. (Right) Axial T2WI
C+ FS MR of the pelvis in a
young girl with vaginal atresia
shows a large T2 bright round
structure corresponding to
hematocolpos .

MR in a girl with vaginal
atresia shows hematocolpos,
with more distension of the
vaginal cavity relative
to the endometrial cavity
. The lower vagina is
replaced with T2 dark signal
corresponding to fibrous
tissue. (Right) Axial T2WI
FSE MR in a patient with
vaginal atresia shows normal-
appearing right and left ovaries
.
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Vagina and Vulva

centered in the midline of the
pelvis shows a small uterus
and an atretic vagina that is
replaced by T2 bright tissue
corresponding to fat replacement
of the lower vagina. (Right) Axial
T2WI FSE MR higher up in the
same girl with vaginal atresia
shows a normal right and left
ovary as the müllerian system
develops normally in vaginal
atresia.

girl with vaginal atresia shows T2
bright signal , corresponding
to fat replacement of the vaginal
fornices. (Right) Axial T2WI
FSE MR higher in the pelvis in
the same patient with vaginal
atresia shows atretic right and left
vaginal fornices replaced by
fat.

centered in the midline in the
pelvis shows an atretic vagina
that is replaced by T2 dark tissue
corresponding to fibrosis that
replaces the lower vagina. Notice
the pelvic kidney deep in the
pelvis . (Right) Axial T2WI
FSE MR in the same girl with
vaginal atresia shows dark T2
linear signal in the expected
location of the vagina, which
represents fibrosis.
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Key Facts
Terminology • MR can be used as problem-solving modality
• Distal vaginal obstruction by a thin endodermal Top Differential Diagnoses
membrane at level of introitus
• Failure of the sinovaginal bulbs to completely canalize • Transverse vaginal septum
o Not considered an anomaly of müllerian duct origin • Vaginal atresia
• Labial adhesions
Imaging • Vaginal agenesis with uterine hypoplasia
• "Bulging" at introitus on physical examination
• Associated hematometrocolpos Clinical Issues
• Normal uterus, vagina, and ovaries • Most frequent obstructive anomaly of vagina
• High signal intensity (SI) blood products in • If complete, symptoms of hematocolpos typically
manifest at menarche
• If incomplete, may be associated with excessive vaginal
hematometrocolpos
• Associated complications: Endometriosis
• Lower margin of vagina ends at introitus secretions and secondary infection
• Surgical hymenotomy at puberty, as onset of
• Membrane is often imperceptible and difficult to estrogenization aids in prevention of adhesions
delineate at imaging
• Transabdominal and transperineal ultrasound used as
initial imaging modality
(Left) Coronal T1WI C+ FS MR

in a young girl presenting with
pelvic pain and imperforate
hymen shows marked
distension of the vaginal
cavity and endometrial
cavity with hyperintense
fluid, corresponding
to blood products and
hematometrocolpos. (Right)
Sagittal T2WI FSE MR
shows hematometrocolpos,
with marked distension of
the vaginal cavity and
endometrial cavity with
T2 isointense blood products.
Examination confirmed
imperforate hymen.

girl with imperforate hymen
demonstrates hematocolpos
with distension of the vaginal
cavity with T1-bright blood
products . (Right) Sagittal
T2WI FS MR in a girl with
imperforate hymen shows
hematometrocolpos with
vaginal and endometrial
distension.
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Vagina and Vulva

TERMINOLOGY Vaginal Atresia
Synonyms
• Lower 1/3 of vagina replaced by fibrous tissue with
associated hematometrocolpos
• Hymenal obstruction o Imperforate hymen always present
Definitions • Normal uterus, ovaries, and upper 2/3 of vagina
• Distal vaginal obstruction by a thin endodermal Labial Adhesions

membrane at level of introitus • Level of obstruction is superficial at level of labia,
• Failure of sinovaginal bulbs to completely canalize which may be fenestrated
o Not considered an anomaly of müllerian duct origin
Vaginal Agenesis With Uterine Hypoplasia
• Loss of normal zonal anatomy of upper 2/3 of vagina
IMAGING o Lower vagina typically preserved
General Features • Rudimentary uterus with distended endometrial cavity
o Very low vaginal obstruction with preservation of CLINICAL ISSUES
vaginal length
o "Bulging" at introitus on physical examination Presentation
o Associated hematometrocolpos • Most common signs/symptoms
o Normal uterus, vagina, and ovaries o Most frequent obstructive anomaly of vagina
o Variable appearance if imperforate hymen is o If complete, symptoms of hematocolpos typically
incomplete manifest at menarche
▪ May present with bladder outlet obstruction due to
MR Findings compression and mass effect by hematocolpos
• T1WI FS o If incomplete, may be associated with excessive
o High signal intensity (SI) blood products in vaginal secretions and secondary infection
hematometrocolpos
o Associated complications: Endometriosis Treatment
• T2WI • Surgical hymenotomy at puberty, as onset of
o Distension of vaginal cavity along its entire length ± estrogenization aids in prevention of adhesions
distension of endometrial cavity
▪ Intraluminal fluid of intermediate to high SI SELECTED REFERENCES
▪ Vagina more distended than endometrial cavity
1. Fischer JW et al: Emergency point-of-care ultrasound
o Lower margin of vagina ends at introitus
diagnosis of hematocolpometra and imperforate hymen in
▪ Membrane often imperceptible and difficult to the pediatric emergency department. Pediatr Emerg Care.
delineate at imaging 30(2):128-30, 2014
2. Domany E et al: Imperforate hymen presenting as chronic
• Distended vaginal ± endometrial cavity
low back pain. Pediatrics. 132(3):e768-70, 2013
3. Ghadian A et al: Is hymenotomy enough for treatment of
o Intraluminal fluid contents variable: Anechoic, imperforated hymen? Nephrourol Mon. 5(5):1012, 2013
hypoechoic with low-level echoes, or echogenic due 4. Salhan B et al: A rare presentation of imperforate hymen: a
to blood products case report. Case Rep Urol. 2013:731019, 2013
o Vaginal cavity more distended than endometrial 5. Vitale V et al: Imperforate hymen causing congenital
hydrometrocolpos. J Ultrasound. 16(1):37-9, 2013
cavity
6. Eksioglu AS et al: Imperforate hymen causing bilateral
Imaging Recommendations hydroureteronephrosis in an infant with bicornuate uterus.
• Best imaging tool Case Rep Urol. 2012:102683, 2012
7. Fedele L et al: A uterovaginal septum and imperforate
o Transabdominal and transperineal ultrasound used
hymen with a double pyocolpos. Hum Reprod.
as initial imaging modality 27(6):1637-9, 2012
o MR can be used as problem solving modality 8. Ruggeri G et al: Vaginal malformations: a proposed
• Protocol advice classification based on embryological, anatomical and
o High-resolution fast spin-echo (FSE) T2WI with clinical criteria and their surgical management (an analysis
of 167 cases). Pediatr Surg Int. 28(8):797-803, 2012
multiplanar imaging
o T1WI with fat suppression 9. Ozturk H et al: Congenital imperforate hymen with bilateral
hydronephrosis, polydactyly and laryngocele: A rare
neonatal presentation. Fetal Pediatr Pathol. 29(2):89-94,
DIFFERENTIAL DIAGNOSIS 2010
10. Johal NS et al: Neonatal imperforate hymen causing
Transverse Vaginal Septum obstruction of the urinary tract. Urology. 73(4):750-1, 2009
• Fibrous septum at junction of middle and upper 1/3 of 11. Adaletli I et al: Congenital imperforate hymen with
hydrocolpos diagnosed using prenatal MRI. AJR Am J
vagina with hematometrocolpos Roentgenol. 189(1):W23-5, 2007
o Isolated or in association with vertical vaginal septa
of müllerian duct anomalies (MDAs)
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Key Facts
Terminology • Thickness of septum should be reported as it may alter
• Incomplete canalization of uterovaginal canal with surgical approach
• MR imaging is modality of choice
urogenital sinus, which forms lower 1/3 of vagina
• Transverse vaginal septum Top Differential Diagnoses
• Isolated or in association with vertical vaginal septa of • Vaginal agenesis with uterine hypoplasia
müllerian duct anomalies (MDAs)
• Imperforate hymen
Imaging • Vaginal atresia
• Distention of vagina superior to septum Clinical Issues
(hematocolpos) with lesser degree of distention of
endometrium (hematometrocolpos) • Presentation most often at menarche with symptoms
• Junction of middle and upper 1/3 of vagina depending on partial or complete
• Blood products in vaginal and endometrial cavity • Complete septum: Cyclic abdominopelvic pain with
enlarging pelvic mass
• May be asymptomatic if partial
consistent with hematometrocolpos
• Associated complications: Endometriosis
• Intraluminal fluid of intermediate or high signal • Surgical resection of septum
intensity due to blood products • Vaginoplasty may be required if septum is thick and
• Septum can be thick and extensive extensive

centered at the vagina shows
separation of the right and left
vaginal fornices by a fibrous
band in this patient with
vaginal septum. (Right) Axial
patient with vaginal septum
lower down shows the T2 dark
fibrous septum separating
the vaginal fornices.
(Left) Longitudinal ultrasound

image in a 12-year-old girl
presenting with severe pelvic
cramping shows marked
distension of the vaginal
echoes corresponding to
hematocolpos. Vaginal septum
was proven surgically. (Right)
Transverse ultrasound image
in the same girl with vaginal
septum shows the rounded
nature of the hematocolpos
.
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Vagina and Vulva

TERMINOLOGY Imperforate Hymen
Definitions
• Distal vaginal obstruction associated with
hematometrocolpos
• Incomplete canalization of uterovaginal canal with • Normal uterus with preserved vaginal length
urogenital sinus, which forms lower 1/3 of vagina
• Transverse vaginal septum Vaginal Atresia
• Isolated or in association with vertical vaginal septa of • Lower 1/3 of vagina replaced by fibrous tissue with
müllerian duct anomalies (MDAs) associated hematometrocolpos
• Normal uterus, ovaries, and upper 2/3 of vagina
IMAGING
CLINICAL ISSUES
General Features
• Best diagnostic clue Presentation
o Distention of vagina superior to septum • Most common signs/symptoms
(hematocolpos) with lesser degree of distention of o Presentation most often at menarche with symptoms
endometrium (hematometrocolpos) depending on partial or complete
• Location o Complete septum: Cyclic abdominopelvic pain with
o Junction of middle and upper 1/3 of vagina enlarging pelvic mass
▪ Inferior vaginal septum in 15% o Partial septum or unilateral septum associated with
• Morphology duplication anomaly
▪ Variable cyclic pain, progressive development of
o Usually linear
hematocolpos/hematometrocolpos
MR Findings ▪ May be asymptomatic if partial
• T1WI FS Natural History & Prognosis
o Blood products in vaginal and endometrial cavity
consistent with hematometrocolpos • Degree of distention of vagina and endometrial cavity
o Associated complications: Endometriosis related to extent of obstruction and time of diagnosis
• T2WI
•
following menarche
Associated with genitourinary, skeletal, cardiovascular,
o Distension of upper vagina ± endometrial cavity
and gastrointestinal anomalies
▪ Intraluminal fluid of intermediate or high signal
intensity due to blood products Treatment
▪ Occasionally fluid/debris levels • Surgical resection of septum
▪ Dilation unilateral in setting of obstructed • Vaginoplasty may be required if septum thick and
complex uterine anomalies extensive
o Vagina more distended than endometrial cavity
▪ Lesser distention of endometrial cavity (usually
1.0 cm) secondary to thicker muscular wall of SELECTED REFERENCES
myometrium 1. Huebner M et al: The rectovaginal septum: visible on
o Septum can be thick and extensive magnetic resonance images of women with Mayer-
▪ Thickness of septum should be reported as it may Rokitansky-Küster-Hauser syndrome (Müllerian agenesis).
alter surgical approach Int Urogynecol J. 25(3):323-7, 2014
2. Lankford JC et al: Congenital reproductive abnormalities. J
Ultrasonographic Findings Midwifery Womens Health. Epub ahead of print, 2013
• Midline, dilated upper vaginal ± endometrial cavity 3. Pascual MA et al: Three-dimensional sonography
for diagnosis of rectovaginal septum endometriosis:
o Intraluminal fluid contents variable: Anechoic,
interobserver agreement. J Ultrasound Med. 32(6):931-5,
hypoechoic with low-level echoes, or echogenic 2013
Imaging Recommendations 4. Krafft C et al: Magnetic resonance as an aid in the diagnosis
• Best imaging tool of a transverse vaginal septum. J Pediatr Surg. 47(2):422-5,

2012
o MR is imaging modality of choice 5. Robbins JB et al: MRI of pregnancy-related issues: müllerian
• Protocol advice duct anomalies. AJR Am J Roentgenol. 198(2):302-10, 2012
o High-resolution fast spin-echo (FSE) T2WI 6. Ruggeri G et al: Vaginal malformations: a proposed
▪ Axial and coronal/sagittal multiplanar imaging classification based on embryological, anatomical and
o T1WI with fat-suppression clinical criteria and their surgical management (an analysis
of 167 cases). Pediatr Surg Int. 28(8):797-803, 2012
7. Marcal L et al: Mullerian duct anomalies: MR imaging.
DIFFERENTIAL DIAGNOSIS Abdom Imaging. 36(6):756-64, 2011
8. Opoku BK et al: Huge abdominal mass secondary to a
Vaginal Agenesis With Uterine Hypoplasia transverse vaginal septum and cervical dysgenesis. Ghana
• Absent normal zonal anatomy of upper 2/3 of vagina Med J. 45(4):174-6, 2011
9. Papaioannou G et al: Magnetic resonance imaging
o Variable degree of upper vaginal distension if residual
visualization of a vaginal septum. Fertil Steril. 96(5):1193-4,
preserved segment 2011
• Lower vagina is typically preserved 10. Miller RJ et al: Surgical correction of vaginal anomalies. Clin
• Rudimentary uterus with distended endometrial cavity Obstet Gynecol. 51(2):223-36, 2008
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Key Facts
• Benign mesenchymal, monoclonal smooth muscle • Vaginal carcinoma
tumor of vagina • Vaginal leiomyosarcoma
Imaging • Vaginal rhabdomyosarcoma
• Solid soft tissue mass arising from vaginal wall • Cervical carcinoma
• Most commonly in midline anterior wall Pathology
• Well-defined, rounded mass with whorled appearance • Little or no mitotic activity or nuclear pleomorphism
• Usually single
• Difficult to evaluate on CECT as they are usually Clinical Issues
isodense to surrounding vaginal and perineal tissue • Very rare
• Homogeneous low signal intensity on both T1 and • Usually occurs in women during their reproductive
T2WI MR years
• Moderate enhancement, ≤ degree of myometrial • Almost always benign
enhancement • Treated with excision and enucleation, usually
• Well-defined, hypoechoic vaginal wall mass on US through vaginal approach
• ~ 10% of leiomyomas in premenopausal women
display focal FDG-18 uptake (max. SUV > 3.0)

color Doppler ultrasound
shows a well-circumscribed,
vascularized mass . Smaller
leiomyomas may be missed on
transvaginal ultrasound if not
clinically suspected. (Right)
Coronal T2WI MR shows a
well-circumscribed, slightly
hyperintense mass arising
from the lower vaginal wall.
Note the low signal intensity
tampon within the vagina.

isointense anterior midline
vaginal wall mass . Note the
low signal intensity tampon
within the vagina. (Right) Axial
patient shows an enhancing
anterior midline vaginal wall
mass . Note the low signal
intensity tampon within
the vagina. The anterior wall
midline location is typical for
vaginal leiomyomas.
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VAGINAL LEIOMYOMA
Vagina and Vulva

Synonyms
o Well-defined hypoechoic mass in vaginal wall
• Vaginal fibroid o Separate from cervix
▪ May be confused for cervical leiomyoma
Definitions o May show cystic degeneration as well-defined
• Benign mesenchymal, monoclonal smooth muscle hypoechoic regions
•
tumor of vagina
Color Doppler
o Usually well vascularized
IMAGING
PET/CT
General Features • ~ 10% of leiomyomas in premenopausal women
• Best diagnostic clue display focal FDG-18 uptake (maximal SUV > 3.0)
o Solid soft tissue mass arising from vaginal wall
• Location
o Anywhere along vagina
o MR shows characteristic features of leiomyoma
▪ Most commonly in midline anterior wall
▪ Be aware of atypical tumors (high signal intensity
▪ Occurrence in posterior wall or off midline is
on T2WI) or complicated lesions
atypical
o Mural in location • Protocol advice
o Small lower vaginal leiomyomas may be difficult to
▪ Most likely grow inwards into vaginal lumen
o Not always associated with uterine leiomyomas visualize on transvaginal ultrasound
▪ Translabial or transperineal approach may be
• Size
helpful
o Between 1-5 cm
o Easier to visualize vaginal leiomyomas by using
• Morphology
ultrasound gel during MR pelvic exams
o Well-defined rounded mass with whorled appearance
• Number
o Usually single DIFFERENTIAL DIAGNOSIS
o Very rarely multiple
Vaginal Carcinoma
CT Findings • Solid, flat, infiltrative heterogeneous mass with features
• Difficult to evaluate on CECT because they are usually of invasion of surrounding tissues
isodense to surrounding vaginal and perineal tissue
Vaginal Leiomyosarcoma
• Presence of vaginal mass may be suspected because of • Bulky, heterogeneous, solid mass
• Invasion of surrounding structures: Uterus, cervix,
contour abnormality or tumoral calcification
• Avidly enhancing tumors may occasionally be seen bladder, and rectum
MR Findings • Moderate to high signal intensity on T2WI
• T1WI Vaginal Rhabdomyosarcoma
o Homogeneous low signal intensity
• • Predominantly tumor of children
• Large heterogeneous mass
T2WI
o Homogeneous low signal intensity
o High signal intensity may be seen due to edema • Moderate to high signal intensity on T2WI
• T1WI C+ FS Cervical Carcinoma
o Usually moderate enhancement, ≤ degree of
myometrial enhancement
• Bulk of mass centered in cervix with possible extension
to vagina
o Marked contrast-enhancement on early arterial phase
is occasionally seen
• MR appearance of complications PATHOLOGY
o Appearance varies according to type of degeneration,
General Features
similar to uterine leiomyomas
▪ Hyaline degeneration
• Genetics
o Most cases are sporadic
– Low signal intensity on T2WI o Syndrome of multiple deep schwannomas, multiple
▪ Myxoid degeneration
nevi (both intradermal and compound types), and
– High signal intensity on T2WI
multiple leiomyomas of vagina have been described
– Usually seen in pregnant women
▪ Inheritance is dominant
▪ Cystic degeneration
– High signal intensity on T2WI Gross Pathologic & Surgical Features
– Cystic areas do not enhance • Resemble uterine leiomyomas
▪ Red degeneration • Well-circumscribed, firm masses
– Peripheral or diffuse high signal intensity on
• Occasionally contain necrosis, edema, or hyalinization
T1WI
– Variable signal intensity ± low signal intensity
• Calcifications may be seen
• Average size 3 cm, range 1-15 cm
rim on T2WI
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Microscopic Features 2. Boskovic V et al: Removal of a vaginal leiomyoma presenting

• Interlacing fascicles of spindle-shaped cells as tumor previa allowing vaginal birth. Eur J Gynaecol
• Elongated, oval nuclei

Oncol. 33(3):326-7, 2012
3. Dane C et al: Vaginal leiomyoma in pregnancy presenting
• Little or no mitotic activity or nuclear pleomorphism as a prolapsed vaginal mass. Hong Kong Med J. 18(6):533-5,
o Diagnosis of vaginal leiomyoma should be reserved 2012
for tumors with < 5 mitoses per 10 high-power fields 4. Hubert KC et al: Clinical and magnetic resonance imaging
▪ ↑ mitotic activity in absence of aggressive behavior characteristics of vaginal and paraurethral leiomyomas: can
they be diagnosed before surgery? BJU Int. 105(12):1686-8,
can be seen during pregnancy 2010
5. Scialpi M et al: Magnetic resonance imaging features of
myxoid leiomyoma of the vagina: A case report. Indian J
CLINICAL ISSUES Radiol Imaging. 19(3):238-41, 2009
Presentation 6. Fasih N et al: Leiomyomas beyond the uterus: unusual
• Most common signs/symptoms locations, rare manifestations. Radiographics.
28(7):1931-48, 2008
o Asymptomatic when small 7. Imai A et al: Leiomyoma and rhabdomyoma of the vagina .
o Palpable mass when large Vaginal myoma. J Obstet Gynaecol. 28(6):563-6, 2008
• Other signs/symptoms 8. Nishizawa S et al: Incidence and characteristics of uterine
o Low back pain may occur leiomyomas with FDG uptake. Ann Nucl Med. 22(9):803-10,
▪ Due to pressure on pelvic ligaments or lumbar 2008
9. Theodoridis TD et al: Vaginal wall fibroid. Arch Gynecol
plexus
Obstet. 278(3):281-2, 2008
o Dyspareunia
10. Sherer DM et al: Sonographic and magnetic resonance
o Dysuria and urinary bladder obstructive symptoms imaging findings of an isolated vaginal leiomyoma. J
▪ Usually due to compression on urethra Ultrasound Med. 26(10):1453-6, 2007
o Large tumors may protrude through introitus 11. Tsai MJ et al: Perineal ultrasonography in diagnosing
o Large vaginal leiomyomas can cause mechanical anterior vaginal leiomyoma resembling a cystocele.
dystocia leading to serious maternal and perinatal Ultrasound Obstet Gynecol. 30(7):1013-4, 2007
complications 12. Bapuraj JR et al: Preoperative embolization of a large vaginal
leiomyoma: report of a case and review of the literature.
Demographics Australas Radiol. 50(2):179-82, 2006
• Age 13. Bukhari AS et al: Vaginal fibroid--a case report. J Obstet
Gynaecol. 25(1):83-4, 2005
o Usually occur in women during their reproductive
14. Gowri R et al: Leiomyoma of the vagina: an unusual
years presentation. J Obstet Gynaecol Res. 29(6):395-8, 2003
▪ Usually 35-50 years of age 15. Shimada K et al: MR imaging of an atypical vaginal
• Epidemiology leiomyoma. AJR Am J Roentgenol. 178(3):752-4, 2002
o Very rare 16. Shadbolt CL et al: MRI of vaginal leiomyomas. J Comput
o Still most common benign vaginal tumor Assist Tomogr. 25(3):355-7, 2001
17. Gorlin RJ et al: Multiple schwannomas, multiple nevi, and
Natural History & Prognosis multiple vaginal leiomyomas: a new dominant syndrome.
• Tend to regress in menopause Am J Med Genet. 78(1):76-81, 1998
• Almost always benign
o Sarcomatous transformation has been reported
• Recurrence after surgery is extremely rare
o Usually seen with tumors with higher mitotic
activity
Treatment
• Excision and enucleation usually through vaginal
approach
o Should be considered before delivery in pregnant
patients to prevent dystocia
• Preoperative embolization may be considered for
vascular tumors
• Well-defined mass, usually arising from midline
anterior vaginal wall, with imaging features identical to
uterine leiomyoma
SELECTED REFERENCES
1. Surabhi VR et al: Magnetic resonance imaging of female
urethral and periurethral disorders. Radiol Clin North Am.
4 51(6):941-53, 2013
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VAGINAL LEIOMYOMA
Vagina and Vulva

(Left) Sagittal T2WI MR in a 47-
with a palpable vaginal mass and
prior hysterectomy for multiple
leiomyomas shows a posterior
vaginal wall mass displaying
heterogeneous high signal
muscles. (Right) Axial T2WI MR
in the same patient shows a right
posterolateral vaginal mural mass
displaying heterogeneous
high signal intensity. Note
the claw of vaginal wall
surrounding the mass.

same patient shows a right
posterolateral vaginal mural mass
that displays signal intensity
similar to or slightly higher
than pelvic skeletal muscles.
(Right) Axial T1WI FS MR in
the same patient shows a right
posterolateral vaginal mural
mass that is well defined
and displays signal intensity
slightly higher than pelvic skeletal
muscles.
(Left) Sagittal T1WI C+ FS MR in

the same patient shows intense
vaginal mural mass . (Right)
vaginal mural mass .
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presented with a palpable
vaginal mass shows a left-
sided vaginal wall mass
displaying very low signal
intensity. (Right) Coronal T2WI
the left vaginal wall mass
displaying very low signal
intensity.

the left vaginal wall mass
displaying low signal
intensity as well as an unusual
exophytic growth pattern into
the perivaginal fat. High signal
gel is present in the vagina.
This is an unusual pattern of
growth for leiomyomas, which
are usually exclusively mural or
grow into the vaginal lumen.
same patient shows the left
vaginal wall mass to have a
signal intensity lower than that
of pelvic skeletal muscles.

exophytic left vaginal wall
mass with signal intensity
lower than that of the pelvic
skeletal muscles. (Right)
same patient shows slightly
heterogeneous but intense
enhancement of the vaginal
mass . Pathology revealed
vaginal leiomyoma.
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VAGINAL LEIOMYOMA
Vagina and Vulva

(Left) Sagittal transvaginal color
Doppler ultrasound in a 42-
with multiple vaginal lesions
shows a large, vascular vaginal
mass indenting the urinary
bladder . (Right) Sagittal
shows a large anterior wall
leiomyoma protruding into
the vaginal lumen. There is also
a small leiomyoma within the
posterior fornix as well as a
large cervical leiomyoma .
The presence of multiple vaginal
leiomyomas is extremely rare.

patient shows a large anterior
wall leiomyoma , which
shows unusually high signal
intensity. Note also a cervical
leiomyoma , which shows
a more characteristic signal
intensity. (Right) Axial T1WI
MR in the same patient shows a
homogeneous vaginal mass
displaying signal intensity similar
to that of pelvic skeletal muscles.
(Left) Sagittal T1WI C+ FS MR in

the same patient shows marked
enhancement of the anterior
vaginal and posterior vaginal
leiomyomata. The cervical
leiomyoma shows moderate
enhancement that is more
characteristic of leiomyomata.
(Right) Axial T1WI C+ FS MR in
vaginal leiomyoma . Because
of the high T2 signal intensity
and marked enhancement,
leiomyosarcoma was suspected.
Biopsy revealed a cellular
leiomyoma.
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Vagina and Vulva VULVAR HEMANGIOMA
Key Facts
• Lobulated, enhancing vulvar mass; may contain linear • Painless, bluish soft tissue mass in vulva
fatty deposits and phlebolith(s) • Occasionally, ulcerations and bleeding may be seen
• Vulvar hemangiomas often involve labia majora, • Hemangiomas may increase in size as a result of
posterior commissure, and clitoris infection, trauma, or hormonal influence (menses,
• MR is most useful to characterize and determine pregnancy)
anatomic extent due to superior contrast resolution
o Hemangiomas usually demonstrate intermediate
• Massive hemangiomas with extensive involvement
of vulva and vagina may create a risk obstruction and
signal intensity between that of muscle and fat bleeding during labor and delivery
o Hemangiomas show intense enhancement
o Hemangiomas have extensive areas of multiple
• Laser therapy, embolotherapy, sclerotherapy, or
surgical resection may relieve symptoms
heterogeneous high signal intensity lobules
Pathology
• Benign tumor resembling normal vessels
• Hemangiomas are seen as red-blue spongy masses
• Dilated, blood-filled cystic spaces lined by flattened
endothelium

a 46 year old with left labial
swelling demonstrates an
elongated T2 hyperintense
mass of the left labia.
Surgical excision of this mass
proved to be a hemangioma.
a lobulated mass in the
left labia corresponding to a
benign vulvar hemangioma.
(Left) Coronal T2WI FS MR

with a vulvar mass shows
a large multifocal lobular
T2 hyperintense mass in
the left vulva. Wide excision
proved a hemangioma
replacing the left vulva. (Right)
with vulvar hemangioma
shows a heterogeneous soft
tissue mass of the left
labium, which contains linear
regions of fat and focal
calcifications .
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VULVAR HEMANGIOMA
Vagina and Vulva

IMAGING PATHOLOGY
General Features General Features
• Best diagnostic clue • Benign tumor resembling normal vessels
o Lobulated, enhancing vulvar mass; may contain
• Hemangiomas are seen as red-blue spongy masses
linear fatty regions and phlebolith(s)
• Location
o Often involve labia majora, posterior commissure, Microscopic Features
and clitoris • Dilated, blood-filled cystic spaces lined by flattened
• Size endothelium
o Varies from small lesions of a few millimeters to
several centimeters
• Morphology CLINICAL ISSUES
o Lobular, can be infiltrating Presentation
CT Findings • Most common signs/symptoms
o Painless, bluish soft tissue mass in vulva
• Hemangiomas show intense enhancement o Occasionally, ulcerations and bleeding may be seen
• Phleboliths in hemangioma may be seen o Hemangiomas may increase in size as a result of
MR Findings infection, trauma, or hormonal influence (menses,
• T1WI pregnancy)
o Hemangiomas usually demonstrate intermediate
signal intensity between that of muscle and fat
o Fatty septa between lobules of mass may be seen • Massive hemangiomas with extensive involvement of
•
vulva and vagina may result in risk obstruction and
T2WI bleeding during labor and delivery
o Hemangiomas have extensive areas of heterogeneous
multiple high signal intensity lobules Treatment
o Central low-signal areas in mass may be due to • None required if asymptomatic
thrombi or flow • Laser therapy, embolotherapy, sclerotherapy, or
• T1WI C+ surgical resection may relieve symptoms
o Demonstrate extensive enhancement
Ultrasonographic Findings SELECTED REFERENCES

• Grayscale ultrasound 1. Sapountzis S et al: Radical resection and reconstruction
o Seen as complex masses with bilateral gluteal fold perforator flaps for vulvar
o Phleboliths may cause acoustic shadowing hemangiolymphangioma. Int J Gynaecol Obstet.
• Color Doppler 121(2):179-80, 2013
2. Gray HJ et al: Painful clitoromegaly caused by rare
o Evaluation may show low-resistance arterial flow
epithelioid hemangioma. Gynecol Oncol Case Rep. 4:60-2,
with forward flow during both systole and diastole 2012
3. Madhu C et al: Vulval haemangioma in an adolescent girl. J
Obstet Gynaecol. 31(2):187, 2011
4. Bruni V et al: Hemangioma of the clitoris presenting as
o MR is most useful to characterize and determine clitoromegaly: a case report. J Pediatr Adolesc Gynecol.
anatomic extent due to superior contrast resolution 22(5):e137-8, 2009
5. Djunic I et al: Diffuse cavernous hemangioma of the left
leg, vulva, uterus, and placenta of a pregnant woman. Int J
DIFFERENTIAL DIAGNOSIS Gynaecol Obstet. 107(3):250-1, 2009
6. Guida M et al: Pregnancy-induced symptomatic pelvic and
Vulvar Cancer extra-pelvic cavernous hemangiomatosis. Clin Exp Obstet
• Soft tissue mass in vulva with necrosis, ulceration, or Gynecol. 36(1):55-7, 2009
lymphadenopathy 7. Wang S et al: Venous malformations of the female
lower genital tract. Eur J Obstet Gynecol Reprod Biol.
Plexiform Neurofibroma 145(2):205-8, 2009
• Occurs in neurofibromatosis 1 8. da Silva BB et al: Vulvar epithelioid hemangioendothelioma.
• May demonstrate "target sign" on T2WI, with central Gynecol Oncol. 105(2):539-41, 2007
9. Gupta R et al: Benign vascular tumors of female genital tract.
low signal that enhances with gadolinium, unlike in
Int J Gynecol Cancer. 16(3):1195-200, 2006
hemangioma
10. Erkek E et al: Clinical and histopathological findings in
Vulvar Endometriosis Bannayan-Riley-Ruvalcaba syndrome. J Am Acad Dermatol.
• Dark red, brown, or bluish papules usually located on 53(4):639-43, 2005
11. Fernández-Aguilar S et al: Spindle cell vulvar
posterior fourchette
• Believed to be a result of surgical implantation during hemangiomatosis associated with enchondromatosis: a
rare variant of Maffucci's syndrome. Int J Gynecol Pathol.
gynecologic surgery such as episiotomy 23(1):68-70, 2004
12. Bava GL et al: Life-threatening hemorrhage from a vulvar
Bartholin Cyst
• Cystic dilatation of Bartholin gland
hemangioma. J Pediatr Surg. 37(4):E6, 2002
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Vagina and Vulva VULVAR HEMANGIOMA
(Left) Longitudinal grayscale

ultrasound of the vulva
demonstrates a lobular
echogenic mass containing
several echogenic nodules
, which proved to be
a multinodular vulvar
hemangioma on resection.
Doppler ultrasound of the
vulva demonstrates a lobular
echogenic mass with
large feeding vessel and
internal vascularity, which
was subsequently proven to
be a vulvar hemangioma on
resection.

a palpable mass on her vulva
shows a linear enhancing
structure of the left labium
and a smaller similar lesion
in the posterior right labium
corresponding to a long
hemangioma, proven on
resection. (Right) Axial T1
C+ subtraction MR image
linear enhancing structure
of the left labium and
a smaller similar lesion in
the posterior right labium
, corresponding to a long
hemangioma proven on
resection.

replacement of the left vulva
by the hemangioma with
extension of the hemangioma
to involve the soft tissues of
the left thigh . (Right) Axial
CECT of a 41-year-old woman
who presented with large
vulvar mass shows a large
heterogeneous mass of the
left labium that contains linear
regions of fat and focal
calcifications representing
phleboliths in this large vulvar
hemangioma.
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VULVAR HEMANGIOMA
Vagina and Vulva

replacement of the left vulva
by the hemangioma with
extension of the hemangioma to
involve the soft tissues of the left
thigh . (Right) Coronal T1WI
C+ FS MR shows enhancement
of the left vulvar hemangioma
with foci extending to involve the
soft tissues of the left thigh .

a palpable mass on her vulva
shows a linear enhancing
structure of the left labium
and a smaller similar lesion
in the posterior right labium
, corresponding to a long
hemangioma proven on
resection. (Right) Coronal T2WI
FS MR shows the relative T2
hyperintense nature of this
well-defined labial hemangioma.
(Left) Axial DWI MR of the

vulva in the same patient
shows marked diffusion of the
labial hemangioma . (Right)
same patient with left labial
hemangioma shows peripheral
enhancement of the lobular
hemangioma.
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Vagina and Vulva VAGINAL PARAGANGLIOMA
Key Facts
• Rare tumor of genital tract • Tumors may be divided into those derived from
• Catecholamine-secreting tumor that arises from parasympathetic or sympathetic ganglia
chromaffin cells of sympathoadrenal system • Arranged in organoid pattern separated into
• Extraadrenal neuroendocrine neoplasms derived from compartments by thin septa, producing cords
neural crest precursors • Typical rounded "ball of cells" alveolar pattern
(zellballen)
Imaging
• Hypervascular lobulated vaginal mass Clinical Issues
• MR: Marked T2 hyperintensity • Catecholamine release can occur secondary to
• Vascular feeding vessels arising from arterial branches intraoperative tumor manipulation during biopsy or
excision
from uterine artery
o Preoperative α-blockade therapy to decrease
• Shows feeding arterial branches from uterine artery incidence of life-threatening complications related
that can be selectively embolized
• Indium-111 (In-111) pentetreotide scintigraphy to excessive catecholamine release from tumor
o Preoperative embolization of tumor
• MIBG scintigraphy with iodine-123(I-123) or I-131 •
• Fluorine-18 (F-18) fluorodihydroxyphenylalanine
May be considered to prevent excessive blood loss
during excision
positron emission tomography

year-old woman presenting
with dyspareunia shows
a lobulated hypervascular
mass in the right vaginal
cuff. Tissue sampling proved
to be a paraganglioma.
(Right) Coronal CECT in
the hypervascular lobular
paraganglioma arising from
the right vaginal cuff.
(Left) Anteroposterior DSA

of the uterine artery shows
several feeding vessels to
the vaginal paraganglioma.
(Right) Anteroposterior DSA
of the right uterine artery
shows several feeding arterial
branches to the vaginal
paraganglioma.
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VAGINAL PARAGANGLIOMA
Vagina and Vulva

o Axial, sagittal, and coronal (short-axis) T2WI with
TERMINOLOGY
small FOV
Synonyms o Sagittal and coronal (short-axis) dynamic T1WI C+ FS
• Vaginal pheochromocytoma with small FOV
Definitions Nuclear Medicine Findings

• Catecholamine-secreting tumor that arises from • Indium-111 (In-111) pentetreotide scintigraphy
chromaffin cells of sympathoadrenal system o High sensitivity (up to 94%) for detection of
• Extraadrenal neuroendocrine neoplasms derived from paraganglioma, especially for lesions > 1.5 cm
neural crest precursors • MIBG scintigraphy with iodine-123 (I-123)
• Rare tumor of genital tract o Fairly sensitive (77-95%) but highly specific
o Can occur in ovary, cervix, and vagina (95-100%) for detection of pheochromocytoma or
paraganglioma
IMAGING PET/CT
General Features • Fluorine-18 (F-18) fluorodihydroxyphenylalanine PET
o Superior to I-123 MIBG scintigraphy in detection of
• Best diagnostic clue extraadrenal paragangliomas, with overall sensitivity
o Hypervascular lobulated vaginal mass
and specificity of up to 98% and 100%, respectively
▪ May see prominent feeding vessels from uterine ▪ PET is more sensitive than I-123 MIBG scintigraphy
artery in noradrenaline secreting and hereditary
• Location paragangliomas
o Vagina
• Size
o 1-5 cm
• Morphology Vaginal Carcinoma
o Well-defined
o Lobulated
• Soft tissue invasive mass, can be difficult to distinguish
by imaging alone
o Invades and extends to uterus, pelvic side wall,
CT Findings
• CECT perineum
o Typically not vascular in nature
o Hypervascular lobular vaginal mass
Vaginal Leiomyoma
MR Findings
• T1WI • T2-hyperintense, enhancing mass
o Typical whorl pattern on T2 and contrast-enhanced
o Isointense lobular mass
images
▪ May have hyperintense foci due to hemorrhage
• • Can prolapse through introitus
•
T2WI
o Marked T2 hyperintensity Bridging myometrial tissue and vessels may help
differentiate
▪ Can be heterogeneous with "speckled" pattern
o Can see prominent feeding uterine arterial feeding Vaginal Hemangioma
branches • Enhancing mass with vascular channels
• T1WI C+ FS • Feeding vessels that can be selectively embolized
o Intense homogeneous enhancement
▪ Delayed persistent enhancement
• Typical flow voids maybe seen
▪ Can see prominent feeding uterine arterial feeding
• May be difficult to differentiate by imaging alone
branches Vaginal Rhabdomyosarcoma
• MRA • Grape-like clusters of tumor
o Vascular feeding vessels arising from arterial • Can prolapse through introitus
branches from uterine artery • T2 hyperintense similar to vaginal paraganglioma
o Conventional angiography
▪ Shows feeding arterial branches from uterine artery
• Usually large and invasive
that can be selectively embolized
• Associated metastatic disease may be present
Vaginal Lymphoma
• Solid echogenic mass with internal vascularity • Diffusely infiltrating tumor of vagina
• Typically not hypervascular mass
• Best imaging tool Vaginal Metastases
• History of known primary
o MR
• Protocol advice
o Pelvic MR with phased-array coil, 4-5 mm slice PATHOLOGY
thickness
o Axial T1WI with larger field of view (FOV) from pelvis Staging, Grading, & Classification
• Tumors may be divided into those derived from
to kidneys for lymph nodes
parasympathetic or sympathetic ganglia 4
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Vagina and Vulva VAGINAL PARAGANGLIOMA
Gross Pathologic & Surgical Features o May be considered to prevent excessive blood loss
• Cells are polygonal with eosinophilic cytoplasm, during excision
resembling those of normal adrenal medulla
• Arranged in organoid pattern separated into DIAGNOSTIC CHECKLIST
compartments by thin septa, producing cords
o Compartments may be round (zellballen), trabecular, Image Interpretation Pearls
or irregular • T2 lobular vaginal mass with intense enhancement
▪ Typical rounded "ball of cells" alveolar pattern
(zellballen)
• Solid nodular yellow and brown mass composed of SELECTED REFERENCES
large, granular eosinophilic cells arranged in cords and 1. Rana HQ et al: Genetic testing in the clinical care of patients
nesting alveolar pattern with pheochromocytoma and paraganglioma. Curr Opin
o Anastomosing endocrine-like capillary network Endocrinol Diabetes Obes. 21(3):166-76, 2014
extends through the fibrous tissue surrounding cell 2. Shuch B et al: The genetic basis of pheochromocytoma and
paraganglioma: implications for management. Urology.
nests
83(6):1225-32, 2014
▪ Produces hypervascular nature of paragangliomas
•
3. Tsirlin A et al: Pheochromocytoma: a review. Maturitas.
Positive immunohistochemical staining for 77(3):229-38, 2014
neurosecretory granule components synaptophysin 4. van Berkel A et al: Diagnosis of endocrine disease:
and chromogranin Biochemical diagnosis of phaeochromocytoma and
paraganglioma. Eur J Endocrinol. 170(3):R109-19, 2014
5. Aktolun C et al: Diagnostic and therapeutic use of MIBG in
CLINICAL ISSUES pheochromocytoma and paraganglioma. Q J Nucl Med Mol
Imaging. 57(2):109-11, 2013
Presentation 6. Dahia PL: Novel hereditary forms of pheochromocytomas
• Most common signs/symptoms and paragangliomas. Front Horm Res. 41:79-91, 2013
o Paragangliomas can occur in isolation 7. Fussey JM et al: Vaginoplasty: a modern approach: a report
▪ Can present as part of multisystemic disorders of 2 cases. J Reprod Med. 58(9-10):441-4, 2013
– Neurofibromatosis type 1, 2 8. Ilha MR et al: Extra-adrenal retroperitoneal paraganglioma
in a dog. J Vet Diagn Invest. 25(6):803-6, 2013
– von Hippel-Lindau disease
9. Kapoor G et al: Phaeochromocytoma in pregnancy:
– Multiple endocrine neoplasia type 2A safe vaginal delivery, is it possible? J Indian Med Assoc.
– Triad of Carney (gastric leiomyosarcoma, 111(4):266-7, 2013
pulmonary chondroma, and extraadrenal 10. Kumar U M et al: An Extra-adrenal Pheochromocytoma
paraganglioma) Presenting as Malignant Hypertension-A Report of two
• Other signs/symptoms cases. J Clin Diagn Res. 7(6):1177-9, 2013
o Postmenopausal bleeding 11. Papathomas TG et al: Paragangliomas: update on differential
o Vaginal mass diagnostic considerations, composite tumors, and recent
genetic developments. Semin Diagn Pathol. 30(3):207-23,
o Heavy vaginal bleeding
2013
o Paroxysmal headaches 12. Rufini V et al: Comparison of metaiodobenzylguanidine
o Palpitations scintigraphy with positron emission tomography in
o Chest pain the diagnostic work-up of pheochromocytoma and
o Elevated levels of urinary vanillylmandelic acid paraganglioma: a systematic review. Q J Nucl Med Mol
(VMA) Imaging. 57(2):122-33, 2013
o Case reports in pregnancy 13. Asfaw TS et al: Utility of preoperative examination and
• Pulsatile vaginal mass on clinical exam

magnetic resonance imaging for diagnosis of anterior
•
vaginal wall masses. Int Urogynecol J. 23(8):1055-61, 2012
Potential massive catecholamine release due to tumor 14. Akl MN et al: Vaginal paraganglioma presenting as a pelvic
manipulation during biopsy or excision mass. Surgery. 147(1):169-71, 2010
o Preoperative α-blockade therapy often necessary 15. Shen JG et al: Vaginal paraganglioma presenting as a
gynecologic mass: case report. Eur J Gynaecol Oncol.
Natural History & Prognosis 29(2):184-5, 2008
• Difficult to differentiate benign and malignant 16. Brustmann H: Paraganglioma of the vagina: report of a case.
paragangliomas by histology Pathol Res Pract. 203(3):189-92, 2007
o Malignancy usually established by local invasion or 17. Elsayes KM et al: Vaginal masses: magnetic resonance
metastases to nonchromaffin tissues imaging features with pathologic correlation. Acta Radiol.
o Follow-up imaging is usually necessary 48(8):921-33, 2007
18. Hassan A et al: Paraganglioma of the vagina: report of a
Treatment case, including immunohistochemical and ultrastructural
• Surgery 19.
findings. Int J Gynecol Pathol. 22(4):404-6, 2003
Lyman DJ: Paroxysmal hypertension, pheochromocytoma,
o Catecholamine release can occur secondary to
and pregnancy. J Am Board Fam Pract. 15(2):153-8, 2002
intraoperative tumor manipulation during biopsy or
excision
o Preoperative α-blockade therapy to decrease
incidence of life-threatening complications related to
excessive catecholamine release from tumor
• Preoperative embolization of tumor
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VAGINAL PARAGANGLIOMA
Vagina and Vulva

(Left) Axial CECT performed
in the arterial phase shows
the arterial hypervascular
paraganglioma. (Right) Axial
CECT performed in the arterial
phase in the same patient shows
the hypervascular polypoid mass
arising from the right vaginal
cuff.
(Left) Coronal CT reconstruction

shows several vascular arterial
branches supplying the vaginal
paraganglioma . (Right)
Axial T1WI C+ FS MR centered
in the pelvis in a 19-year-old
woman with vaginal pain shows
a lobulated vascular mass
arising in the left vaginal cuff.
Surgical excision proved to be a
vaginal paraganglioma.

paraganglioma shows the
vascular nature of this tumor.
(Right) Sagittal T2WI FS MR in
paraganglioma shows the relative
T2-hyperintense nature of this
polypoid mass.
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Vagina and Vulva VAGINAL CARCINOMA

(T) Primary Tumor
T1 I Tumor confined to vagina
T2 II Tumor invades paravaginal tissues but not to pelvic wall
T3 III Tumor extends to pelvic wall²
T4 IVA Tumor invades mucosa of bladder or rectum &/or extends beyond true pelvis (bullous
edema is not sufficient evidence to classify a tumor as T4)

N1 III Pelvic or inguinal lymph node metastasis

M1 IVB Distant metastasis

²Pelvic wall is defined as muscle, fascia, neurovascular structures, or skeletal portions of the bony pelvis. On rectal examination,
there is no cancer-free space between the tumor and pelvic wall.

Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T1-T3 N1 M0
T3 N0 M0
IVA T4 Any N M0
IVB Any T Any N M1
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VAGINAL CARCINOMA
Vagina and Vulva

Tis T1: Invasive Sqamous Cell Carcinoma
H&E stain shows dysplastic cells with enlarged and pleomorphic Low-power magnification of H&E stain shows nonstratified
nuclei and high nuclear to cytoplasmic ratio involving the full squamous epithelium of vaginal mucosa with invasive squamous
thickness of the mucosa. Numerous dysplastic cells extend all the cell carcinoma. Both the mucosal surface and irregular
way to the surface . Mitotic figures are evident . basement membrane are highlighted. A few nests are noted
deeper in the submucosa .
T1: Invasive Sqamous Cell Carcinoma T3
Higher magnification of the lower aspect of the mucosa shows The tumor extends to the pelvic wall (T3). H&E stain from a pelvic
an irregular basement membrane with projections of cords wall nodule shows vaginal squamous carcinoma. Note the nests
and nests of cells into the submucosa, indicating an invasive and sheets of neoplastic squamous cells invading into the
component. fibroconnective tissue and fascia of the pelvic wall.
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T1 T2
Graphic illustrates a T1 tumor. The tumor is confined to the vagina Graphic illustrates a T2 tumor. The tumor invades paravaginal
and does not invade the paravaginal tissues. tissues but does not reach to the pelvic wall.
T3 T4
Graphic illustrates a T3 tumor. The tumor invades paravaginal Graphic illustrates a T4 tumor. The tumor invades mucosa of the
tissues and extends to the pelvic wall. The pelvic wall is defined as bladder (to the left of the divider) or rectum (to the right of the
muscle, fascia, neurovascular structures, or bony pelvis. divider). T4 disease may also be characterized by extension beyond
the true pelvis.
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VAGINAL CARCINOMA
Vagina and Vulva

Nodal Drainage of Vagina Nodal Drainage of Vagina
Graphic illustrates nodal drainage of tumors arising in the lower 1/3 Graphic illustrates nodal drainage of tumors arising in the upper
of the vagina. Those tumors spread to inguinal and femoral lymph 2/3 of the vagina. Those tumors spread to pelvic lymph nodes,
nodes. including obturator and internal and external iliac nodes.

Lung
Liver
Bone
Skin
Because vaginal carcinoma is a rare tumor, there are no data

present in the literature describing the incidence of distant
metastases. Metastatic sites described in the literature include
lungs, liver, bones, and skin.
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– Up to 30% of patients have history of

OVERVIEW intraepithelial or invasive carcinoma of cervix or
General Comments vulva
o Adenocarcinoma
• Vaginal involvement with malignant disease occurs ▪ Thought to arise from
more commonly from metastatic spread
o Most commonly due to direct local invasion from – Areas of vaginal adenosis
– Foci of endometriosis
female urogenital tract
– Wolffian rest remnants
• Vaginal carcinoma should be diagnosed only if other – Periurethral glands
gynecologic malignancies have been excluded
o Tumor involving cervix, including external os, ▪ Develop in up to 2% of women exposed in utero to
diethylstilbestrol (DES)
should always be assigned to carcinoma of cervix
o Tumor involving vulva and extending to vagina – 2/3 have history of in utero exposure to DES
– Associated with congenital T-shaped uterus
should always be classified as carcinoma of vulva
o Different clinical approaches in treatment of cervical • Epidemiology & cancer incidence
o Uncommon tumor comprising 1-2% of gynecologic
and vulvar carcinoma
malignancies
Classification ▪ 5th in frequency behind carcinoma of ovary,
• Tumors involving vagina can be uterus, cervix, and vulva
o Squamous cell carcinoma o 2,160 estimated new cases in USA in 2009
▪ ~ 85-90% of cases ▪ Highest incidence among African American
o Adenocarcinoma women (1.24 per 100,000 person-years)
▪ ~ 10% of cases o 770 estimated deaths in USA in 2009
o Adenosquamous carcinoma o Age of presentation depends on histological type
▪ ~ 1-2% of cases ▪ Squamous cell carcinoma
o Melanoma – Predominantly in postmenopausal women
o Sarcoma – Mean age ± standard deviation at diagnosis was
65.7 ± 14.3 years
▪ Adenocarcinoma
PATHOLOGY – Typically occurs in younger women ages 14–21
years (peak age: 19 years)
Routes of Spread – Majority are clear cell histology
• Local spread • Associated diseases, abnormalities
o Tumor spreads locally into paravaginal soft tissues o Vaginal carcinoma frequently found in association
and eventually to pelvic side wall, mucosa of bladder, with vaginal intraepithelial neoplasia
or rectum
• Lymphatic spread Gross Pathology & Surgical Features
o Early spread to regional lymph nodes • Most common patterns of presentation of vaginal
▪ 1/3 of patients have pelvic or groin lymph node squamous cell carcinoma
o Ulcerating lesion (50%)
involvement at diagnosis
o Nodal spread usually depends on site of primary o Fungating mass (30%)
o Annular constricting mass (20%)
tumor
▪ Expected nodal disease pathways • Tumor location in vagina depends on tumor histologic
– Upper and middle 1/3 of vagina → pelvic type
obturator nodes, internal and external iliac
▪ Occurs mainly in upper 1/3 on posterior wall
nodes, and paraaortic nodes o Adenocarcinoma
– Lower 1/3 of vagina → inguinal and femoral
▪ Occurs mainly in upper 1/3 on anterior wall
nodes
– Disease progression or tumor involving whole Microscopic Pathology
length of vagina may spread to inguinal and iliac • Squamous cell carcinoma
nodes o Tumor composed of malignant squamous cells
o Lymphatic drainage does not always follow expected o Tumors can be graded as
lymphatic channels as predicted by anatomic tumor ▪ Well differentiated
location ▪ Moderately differentiated
• Hematogenous spread ▪ Poorly differentiated
o Most common sites of distant metastases are lung, ▪ Undifferentiated
liver, and bone o Squamous cell carcinoma can be
▪ Keratinizing
General Features
▪ Nonkeratinizing
• Etiology o Subtypes of squamous cell carcinoma include
▪ Verrucous
▪ Squamous carcinoma of vagina is associated with
▪ Warty
human papilloma virus (HPV)
▪ Spindle
– HPV viral particles can be identified in ~ 60% of
• Adenocarcinoma
4 invasive squamous cancers of vagina o Clear cell adenocarcinoma
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VAGINAL CARCINOMA
Vagina and Vulva

▪ Tumor cells have clear or eosinophilic cytoplasm – Local extension to bladder or urethra and rectum
▪ Type of vaginal adenocarcinoma related to DES – Regional lymph node involvement
exposure ▪ T1
▪ May be seen next to areas of adenosis in older – Tumor limited to vaginal mucosa
women – Appears as mass or plaque of tissue of
o Endometrioid adenocarcinoma intermediate signal intensity on T2WI,
▪ Closely resemble morphology of uterine expanding and filling vagina
endometrial carcinoma – Preservation of low signal intensity of outer
▪ May be seen in association with adenosis or vaginal muscularis layer
endometriosis ▪ T2
o Mucinous adenocarcinoma – Extension into paravaginal tissue
▪ Rare in vagina – Paravaginal fat is of abnormal low signal
▪ Can be of endocervical or enteric (contain goblet intensity on T1WI
cells) types – Loss of low signal intensity of vaginal muscularis
o Mesonephric adenocarcinoma layer
▪ T3
– Tumor extends to pelvic sidewall (defined as
IMAGING FINDINGS muscle, fascia, neurovascular structures, or
skeletal portions of bony pelvis)
Detection – Best seen on axial and coronal T2WI
• CT – Intermediate signal intensity tumor extends to
o Detection of vaginal carcinoma is difficult with CT and infiltrates low signal intensity muscles of
▪ In 1 study, CT detected vaginal carcinoma in only pelvic sidewall and floor
43% of patients ▪ T4
o Tumors are only seen if large enough to alter vaginal – Invasion of bladder or rectal mucosa
contour – Spreads beyond pelvis and may involve
• MR peritoneum and small or large bowel loops
o Location and extent are best assessed with high- – Best evaluated on T2-weighted images
resolution T2WI – Invasion through low signal intensity of bladder
o Improved detection of vaginal pathology by or rectal wall
intravaginal instillation of ultrasound gel – Loss of fat planes between vagina and bladder or
o Appearance on MR imaging correlates with rectum
macroscopic patterns of disease – Presence of bullous edema is not sufficient
▪ Ill-defined, irregular, diffuse mass (ulcerating evidence to classify a tumor as T4
pattern of disease) o CT
▪ Well-defined lobulated mass (fungating pattern of ▪ Except in advanced disease, CT is not helpful for
disease) local staging
▪ Circumferential thickening (annular constricting – Poor soft tissue characterization
pattern of disease) • Nodal metastases
o T1WI o CT and MR can be equally useful in evaluating
▪ Isointense to muscle regional lymph nodes
▪ May be difficult to see unless large enough to alter o PET/CT is superior to CT in identification of nodal
vaginal contour metastases
o T2WI o Lymphoscintigraphy can be helpful in detection of
▪ Mass of homogeneous intermediate signal nodal metastases
intensity distinct from low signal intensity of ▪ Nodal metastases do not always follow predicted
vaginal wall drainage patterns based on location
▪ Hyperintense to muscles, lower than that of fat ▪ May result in change of radiation field
▪ Presence of high signal intensity foci likely due to • Distant metastases
tumoral necrosis should raise possibility of o CT or PET/CT are modalities of choice for evaluation
– Poorly differentiated squamous cell carcinoma of distant metastases
– Adenosquamous carcinoma o Lung metastatic nodules from squamous cell
– Mucinous adenocarcinoma carcinoma frequently cavitate
• FDG PET
o In 1 study, FDG PET identified abnormal vaginal Restaging
uptake in 100% of patients with primary vaginal • CT or PET/CT is useful for detection of recurrent or
carcinoma metastatic tumor
Staging
• Local disease CLINICAL ISSUES
o MR
▪ Crucial in demonstrating Presentation
– Tumor location • Patients usually present with following symptoms
o Painless vaginal bleeding (65–80%)
4
– Parametrial extension
– Pelvic sidewall involvement o Abnormal discharge (30%)
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o Urinary symptoms (20%) ▪ Combination of interstitial (single-plane implant)
o Pelvic pain (15–30%) and intracavitary therapy
o Feeling of vaginal mass (10%) ▪ For lesions of lower 1/3 of vagina, elective radiation
o Asymptomatic (10–27%) therapy to pelvic ± inguinal lymph nodes
▪ Combined local therapy in selected cases, which
Cancer Natural History & Prognosis may include wide local excision, lymph node
• 5-year survival depends on stage sampling, and interstitial therapy
o Stage 0 (85%) o Stage II squamous cell carcinoma or adenocarcinoma
o Stage I (61%) ▪ Combination of brachytherapy and EBRT
o Stage II (48%) ▪ For lesions of lower 1/3 of vagina, elective radiation
o Stage III (34%) therapy to pelvic &/or inguinal lymph nodes
o Stage IVA (22%) ▪ Radical vaginectomy or pelvic exenteration ±
o Stage IVB (11%)
radiation therapy
• Exophytic tumors are associated with significantly o Stage III, IVA squamous cell carcinoma or
better prognosis than infiltrative ones adenocarcinoma
o Possibly because exophytic tumors tend to grow ▪ Combination of interstitial, intracavitary, and
more superficially, while infiltrative lesions are more EBRT
likely to invade adjacent pelvic structures – Surgery may rarely be combined with above
o Stage IVB squamous cell carcinoma or
Treatment Options
• Treatment options by stage adenocarcinoma
o Squamous cell carcinoma in situ ▪ Radiation (for palliation of symptoms) ±
▪ Wide local excision ± skin grafting chemotherapy
▪ Partial or total vaginectomy with skin grafting for
multifocal or extensive disease
▪ Intravaginal chemotherapy with 5% fluorouracil REPORTING CHECKLIST
cream
▪ Laser therapy
T Staging
▪ Intracavitary radiation therapy delivering 60-70 Gy • MR is imaging modality of choice for assessment of
to mucosa local tumor
o Tumor limited to vaginal mucosa is T1
– Entire vaginal mucosa should be treated
o Stage I squamous cell carcinoma o Extension into paravaginal tissue is T2
o Extension to pelvic sidewall is T3
▪ Superficial lesions < 0.5 cm thick
o Invasion of bladder or rectal mucosa, spread beyond
– Intracavitary radiation therapy
– External beam radiation therapy (EBRT) for pelvis, or involvement of peritoneum and small or
bulky lesions large bowel loops is T4
– For lesions of lower 1/3 of vagina, elective N Staging
radiation therapy to pelvic ± inguinal lymph • CT, MR, PET/CT, or lymphoscintigraphy for detection
nodes of nodal disease
– Wide local excision or total vaginectomy with • May involve inguinal, femoral, pelvic, or paraaortic
vaginal reconstruction, especially in lesions of nodes
upper vagina
– In cases with close or positive surgical margins, M Staging
adjuvant radiation therapy should be considered • CT or PET/CT for detection of distal metastases
▪ Lesions > 0.5 cm thick • Lung is most common site for distal metastases
– Upper 1/3: Radical vaginectomy + pelvic
lymphadenectomy ± construction of neovagina
– Lower 1/3: Radical vaginectomy + inguinal SELECTED REFERENCES
lymphadenectomy
– Adjuvant radiation therapy in cases with close or Manual. 7th ed. New York: Springer. 387-93, 2010
positive surgical margins 2. Shah CA et al: Factors affecting risk of mortality in women
– Combination of interstitial (single-plane with vaginal cancer. Obstet Gynecol. 113(5):1038-45, 2009
implant) and intracavitary therapy 3. Griffin N et al: Magnetic resonance imaging of vaginal and
– EBRT for poorly differentiated or infiltrating vulval pathology. Eur Radiol. 18(6):1269-80, 2008
tumors 4. Parikh JH et al: MR imaging features of vaginal
– Elective radiation therapy to pelvic ± inguinal malignancies. Radiographics. 28(1):49-63; quiz 322, 2008
5. Taylor MB et al: Magnetic resonance imaging of primary
lymph nodes vaginal carcinoma. Clin Radiol. 62(6):549-55, 2007
o Stage I adenocarcinoma
6. Lamoreaux WT et al: FDG-PET evaluation of vaginal
▪ Total radical vaginectomy + hysterectomy with carcinoma. Int J Radiat Oncol Biol Phys. 62(3):733-7, 2005
lymph node dissection
– Upper vagina: Deep pelvic node dissection
– Lower vagina: Inguinal node dissection
▪ Adjuvant radiation therapy in cases with close or
4
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VAGINAL CARCINOMA
Vagina and Vulva

Stage I (T1 N0 M0) Stage I (T1 N0 M0)
year-old woman, who had a
hysterectomy at the age of 40
due to uterine leiomyomas,
shows an intermediate-signal
tumor involving the right
anterior aspect of the gel-
filled vagina . Tumor is
limited by the vaginal wall
with no invasion of the
paravaginal tissues. (Right)
patient shows the tumor
involving the upper and
middle 1/3 of the vagina.

tumor with no extension
into the paravaginal fat
or extravaginal enhancing
nodules. (Right) Sagittal T1WI
C+ FS MR in the same patient
shows the enhancing tumor
with a clear plane
between the vaginal tumor
and the contrast-filled urinary
bladder.

(Left) Axial PET/CT in the
same patient shows increased
metabolic activity within
the vaginal mass . (Right)
Coronal PET/CT in the same
patient shows increased
the vaginal mass . No
other metastatic lesions
were detected. A tumor
limited to the vagina without
paravaginal involvement
constitutes T1 disease.
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shows a lobulated mass of
intermediate signal intensity
filling the left posterior vaginal
fornix. There is no extension
outside the vagina. (Right)
patient shows a polypoid
vaginal carcinoma filling
the left side of the posterior
vaginal fornix. The low signal
intensity cervical stroma
is intact without evidence of
invasion.

shows a large polypoid mass
expanding the vaginal
lumen. The cervix is not
involved. (Right) Coronal
shows a vaginal mass with
irregular nodular interface
with the paravaginal
tissues due to paravaginal
fat invasion. Paravaginal fat
invasion without extension to
the pelvic wall represents T2
disease.

tumor filling the vagina
with paravaginal invasion
and disruption of the low
signal intensity vaginal wall.
(Right) Axial T1WI C+ MR
an enhancing vaginal mass
with bilateral extension
into the paravaginal fat .
Note the clear interface
anteriorly between the vagina
and the posterior wall of the
urinary bladder.
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VAGINAL CARCINOMA
Vagina and Vulva

to the right of the midline
in a 45-year-old woman,
who presented with vaginal
bleeding and discharge,
shows circumferential
thickening of the vaginal wall
involving almost the entire
length of the vagina. (Right)
patient close to the midline
vaginal wall . The cervix
is normal. The tumor
extends into the anterior
vaginal fornix .

thickening of the vaginal
wall with extension into
the right paravaginal fat
tumor extension involving the
right side of the rectum .
Compare this to the clear fat
plane between the vagina
and anterior left aspect of the
rectum . The low signal
intensity around the urethra
is preserved with no
evidence of tumor invasion.

rounded and irregular right
pelvic lymph node .
same patient shows tumor
extending into the paravaginal
fat . MR imaging should
include imaging without
fat suppression to allow
visualization of intermediate
signal linear or nodular tumor
extension into paravaginal fat.
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(Left) Axial T2WI MR in an
ureteric duplication, who
presented with vaginal
bleeding, shows a slightly
hyperintense heterogeneous
vaginal mass with
extension into the rectum
the vaginal mass with
extension to involve a right-
side low inserting ectopic
ureter .

shows an enhancing vaginal
mass with extension into
the rectum . Note also
the rounded right inguinal
enhancing lymph nodes .
vaginal enhancing mass
extending into the rectal wall
with enhancement of the
rectal mucosa .

65-year-old woman who
presented with vaginal
bleeding shows a vaginal
mass of intermediate
signal intensity that extends
through the paravaginal fat
to involve the pelvic side wall
and rectum . (Right)
mass with enhancing soft
tissue extending to involve
the pelvic side wall and
rectum .
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VAGINAL CARCINOMA
Vagina and Vulva

shows the vaginal mass
with lateral extension
to the pelvic side wall .
vaginal mass with anterior
extension to involve the
posterior wall of the urinary
bladder and posterior
extension to involve the
rectum .
Metastatic Vaginal Carcinoma Metastatic Vaginal Carcinoma

old woman who underwent
radical vaginectomy for
stage II vaginal squamous
carcinoma shows no
evidence of local recurrence.
(Right) Axial CECT lung
window in the same patient
shows a cavitary lung
lesion . Metastases
from squamous carcinoma
frequently cavitate. CT
is useful for follow-up
in patients with vaginal
carcinoma for detection of
local recurrence or metastatic
disease.
Local Recurrent Vaginal Carcinoma Local Recurrent Vaginal Carcinoma

originally presented with
stage III vaginal carcinoma
and underwent radiation
treatment shows a vaginal
mass with extension to the
paravaginal tissue and to
the rectum . (Right) Axial
CECT in the same patient also
shows extension to the pelvic
muscles and left ischium
.
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Vagina and Vulva VAGINAL LEIOMYOSARCOMA
Key Facts
• Malignant mesenchymal vaginal neoplasm • Vaginal leiomyoma
Imaging • Vaginal carcinoma
• Usually arises from upper vagina • Cervical carcinoma with vaginal extension
• Commonly involves posterior vaginal wall but may Pathology
occur anywhere along vagina • Association with prior pelvic irradiation has been
• May invade surrounding structures: Cervix, bladder, reported
ureter, &/or rectum • Mitotic counts of > 5 per 10 high-power fields
• Can reach large size and displace uterus superiorly
• CECT: Large, mixed solid and cystic mass with Clinical Issues
heterogeneous enhancement • Usually present as asymptomatic vaginal mass
• MR • Average age at diagnosis is 47 years
o T1WI: Homogeneously iso- or hypointense mass • ~ 1% of all vaginal cancers
o T2WI: Heterogeneously hyperintense mass
o T1WI C+ FS: Heterogeneous enhancement
• Prognosis is poor as a result of early hematogenous
dissemination and frequent local recurrence
• US: Heterogeneous mass with hypoechoic cystic areas • Treatment includes wide surgical excision, ensuring
indicating tumor necrosis disease-free margins

49-year-old woman shows a
with signal intensity similar
to that of the pelvic skeletal
muscles. (Right) Axial T2WI
a heterogeneous vaginal mass
arising from the right lateral
wall. Small areas of high signal
intensity represent areas of
cystic changes/necrosis. Clear
fat planes are present around
the mass with no evidence
of invasion of surrounding
structures.

heterogeneous mass
expanding the lower vagina,
with small areas of high T2
signal intensity due to cystic
changes/necrosis. (Right)
same patient shows avid
mass . Wide surgical
excision was performed,
and pathological evaluation
revealed leiomyosarcoma.
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VAGINAL LEIOMYOSARCOMA
Vagina and Vulva

TERMINOLOGY PATHOLOGY
Definitions General Features
• Malignant mesenchymal vaginal neoplasm • Etiology
o Association with prior pelvic irradiation has been
reported
IMAGING o Unknown if leiomyosarcoma arises de novo or as
General Features malignant change from leiomyoma
• Location Gross Pathologic & Surgical Features
o Usually arises from upper vagina
o Commonly involves posterior vaginal wall but may
• > 3 cm diameter pale/yellow tumor with areas of
hemorrhage, necrosis, ± cystic change
occur anywhere along vagina
o May invade surrounding structures: Cervix, bladder, Microscopic Features
ureter, &/or rectum • Marked cytological atypia
▪ Can completely obstruct cervix (causing • Mitotic counts of > 5 per 10 high-power fields
hydrometra) or ureter (causing hydroureter and • Infiltrating margins
hydronephrosis)
• Size
CLINICAL ISSUES
o Can reach large size and displace uterus superiorly
• Morphology Presentation
o Friable, exophytic mass
CT Findings o Usually present as asymptomatic vaginal mass
• Large, mixed solid and cystic mass • Other signs/symptoms
o Vaginal, rectal, or bladder pain
• Heterogeneous enhancement on CECT o Vaginal discharge, bleeding, or leukorrhea
• Areas of low attenuation correspond to regions of o Dyspareunia
tumor necrosis
o Difficulty in micturition
MR Findings
• T1WI Demographics
• Age
o Homogeneously iso- or hypointense mass
o Wide range (17-69 years)
• T2WI
▪ Average: 47 years
o Heterogeneously hyperintense mass
• T1WI C+ FS • Epidemiology
o Rare tumor
o Heterogeneous enhancement
▪ ~ 1% of all vaginal cancers
Ultrasonographic Findings ▪ ~ 0.01% of all gynecological malignancies
• Heterogeneous mass with hypoechoic cystic areas Natural History & Prognosis
indicating tumor necrosis
• May be difficult to discern whether primary tumor • Prognosis is poor due to early hematogenous
dissemination and frequent local recurrence
arises from vagina or cervix
Treatment
• Best imaging tool • Wide surgical excision, ensuring disease-free margins
o MR for local tumor staging (to define extension • Radiation therapy or adjuvant chemotherapy if tumor
extends beyond surgical margins
to cervix, bladder, &/or rectum) and evaluation of
lymph nodes
o CT for evaluation of distant metastasis (lung, liver, SELECTED REFERENCES
and bone) 1. Yang DM et al: Leiomyosarcoma of the vagina: MR findings.
Clin Imaging. 33(6):482-4, 2009
2. Parikh JH et al: MR imaging features of vaginal
DIFFERENTIAL DIAGNOSIS malignancies. Radiographics. 28(1):49-63; quiz 322, 2008
Vaginal Leiomyoma 3. Suh MJ et al: Leiomyosarcoma of the vagina: a case
• Well-defined vaginal mass

report and review from the literature. J Gynecol Oncol.
•
19(4):261-4, 2008
Usually, homogeneous low T2 signal intensity 4. Ben Amara F et al: Primary leiomyosarcoma of the vagina.
Case report and literature review. Tunis Med. 85(1):68-70,
Vaginal Carcinoma
• Irregular, infiltrative mass
2007
5. Ahram J et al: Leiomyosarcoma of the vagina: case report
and literature review. Int J Gynecol Cancer. 16(2):884-91,
Cervical Carcinoma With Vaginal Extension 2006
• Heterogeneous mass centered in uterine cervix with 6. Moller K et al: Primary leiomyosarcoma of the vagina:
extension to vagina a case report involving a TVT allograft. Gynecol Oncol.
94(3):840-2, 2004
7. Szklaruk J et al: MR imaging of common and uncommon
large pelvic masses. Radiographics. 23(2):403-24, 2003
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Key Facts
Terminology • Vaginal yolk sac tumor
• Solid tumor originating in vagina • Hydrometrocolpos
o Botryoid rhabdomyosarcoma subtype
Pathology
• Intraluminal mass composed of smooth grape-like • Embryonal (60% all rhabdomyosarcoma): Primitive
clusters of tumor
cells with tadpole or bipolar appearance or spindle
Imaging shape (spindle cell variant)
• US for screening a child with suspected pelvic mass Clinical Issues
• MR for accurate assessment of local tumor extent • Mass in vagina, vulva, and perineum prolapsing into
• Areas of hemorrhage show variable signal intensity introitus
depending on stage of evolution • Bimodal age distribution: Average 7 years old with 1st
• T1W C+ FS: Heterogeneous enhancement peak at 3 and 2nd at 15 years
• Internal vascularity on color Doppler US • Relatively good prognosis if early detection
• CT for detection of pulmonary metastases • Local recurrence is common
• MR for local recurrence • Neoadjuvant chemotherapy followed by surgery
• Bladder rhabdomyosarcoma

with anemia and renal failure
mass arising from
the pelvis involving the
cervix and vagina. Surgical
pathology showed embryonal
rhabdomyosarcoma. (Right)
Longitudinal ultrasound in the
same patient with embryonal
rhabdomyosarcoma shows
the large echogenic mass
and endovaginal canal.

MR in a 14-year-old girl
who presented with a
mass protruding from the
vagina and vaginal bleeding
shows an elliptical soft
tissue mass protruding
into the introitus between
the labia. Surgical excision
proved to be an embryonal
Coronal T2WI FS MR in
pedunculated T2-hyperintense
mass extending from vagina
into the introitus between
labia , corresponding
to patient's embryonal
4 rhabdomyosarcoma.
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TERMINOLOGY • Genetics
o Syndromic NF, Li-Fraumeni syndrome (autosomal
Abbreviations dominant), Costello syndrome (autosomal recessive,
• Embryonal rhabdomyosarcoma (RMS) redundant skin, papilloma, and somatomegaly)
Definitions • Associated abnormalities
o Metastases to lungs, liver, bone, and lymph nodes
• Common tumor of lower genitourinary tract in
children Staging, Grading, & Classification
• I: Localized with complete resection
IMAGING • II: Residual tumor post resection
• III: Gross residual disease
General Features • IV: Distant metastases (14%)
• Location Microscopic Features
o Botryoid rhabdomyosarcoma
▪ Variant of embryonal rhabdomyosarcoma • Cells similar to maturational stages of fetal muscle:
characteristically occurring in vagina and bladder From primitive mesenchymal tumors to well-
▪ Intraluminal mass composed of smooth grape-like differentiated cells
clusters of tumor • Botryoid embryonal variant: Polypoid, edematous
growth, beneath intact mucosa
CT Findings
• Large, heterogeneous soft tissue mass CLINICAL ISSUES
MR Findings
• T1WI: Show areas of hemorrhage with variable signal Presentation
intensity (SI) depending on stage of evolution
• T2WI: Large pelvic mass of high SI; multiple thin low o Mass in vagina, vulva, and perineum prolapsing into
introitus
SI septa within mass with grape-like appearance in
botryoid subtype o Vaginal bleeding
• T1W C+ FS: Heterogeneous enhancement Demographics
Ultrasonographic Findings • Age
• Echogenic masses with lucent foci represent areas of o Bimodal distribution: Average 7 years old with 1st
peak at 3 and 2nd peak at 15 years
necrosis or hemorrhage
• Internal vascularity on color Doppler US Natural History & Prognosis
Imaging Recommendations • Relatively good prognosis if detected early
• Protocol advice • Local recurrence is common
o US for screening a child with suspected pelvic mass
Treatment
o MR for accurate assessment of local tumor extent,
local recurrence
• Neoadjuvant chemotherapy followed by surgery
o CT/MR for detection of inguinal and retroperitoneal
lymph nodes and bone metastases DIAGNOSTIC CHECKLIST
Consider
DIFFERENTIAL DIAGNOSIS • Embryonal rhabdomyosarcoma in infant or young
child presenting with a large pelvic mass
Bladder Rhabdomyosarcoma
• Infiltrative vaginal tumors involving the urinary
bladder may be indistinguishable from bladder tumors SELECTED REFERENCES
invading the vagina 1. Kirsch CH et al: Outcome of female pediatric patients
Vaginal Yolk Sac Tumor diagnosed with genital tract rhabdomyosarcoma based on
• When large, indistinguishable from analysis of cases registered in SEER database between 1973
and 2006. Am J Clin Oncol. 37(1):47-50, 2014
rhabdomyosarcoma on imaging alone
• Elevated serum levels of α-fetoprotein levels
2. Hemida R et al: Embryonal rhabdomyosarcoma of the
female genital tract: 5 years' experience. J Exp Ther Oncol.
10(2):135-7, 2012
Hydrometrocolpos 3. Mandong BM et al: Childhood rhabdomyosarcoma: a review
• High SI on T1WI, low SI on T2WI, associated with of 35 cases and literature. Niger J Med. 20(4):466-9, 2011
congenital vaginal and uterine duplication anomalies 4. Kobi M et al: Sarcoma botryoides: MRI findings in two
patients. J Magn Reson Imaging. 29(3):708-12, 2009
5. Parikh JH et al: MR imaging features of vaginal
PATHOLOGY malignancies. Radiographics. 28(1):49-63; quiz 322, 2008
General Features
• Etiology
o Embryonal (60% all RMS): Primitive cells with
tadpole or bipolar appearance or spindle shape
(spindle cell variant) 4
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MR in a 14-year-old girl with
vaginal bleeding and mass
protruding from vagina shows
a pedunculated soft tissue
mass with a stalk that
extends from the vagina into
the introitus between the
labia . Surgical pathology
confirmed embryonal
Sagittal CECT in a 16-year-
old girl who presented with
vaginal bleeding shows a large
"botryoid" soft tissue mass
expanding the vagina. Surgical
pathology showed embryonal
rhabdomyosarcoma.

in a 2-year-old girl with
vaginal embryonal
a large echogenic mass
replacing the vagina. (Right)
with vaginal embryonal
internal vascularity to the
mass.

in a 2-year-old girl who
presented with blood clots in
diaper show a large expansile
vaginal mass . Embryonal
rhabdomyosarcoma was
proven on surgical pathology.
intense enhancement of
the large vaginal embryonal
rhabdomyosarcoma.
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of the pelvis shows the grape-
like cluster/botryoid-like nature
of the vaginal embryonal
rhabdomyosarcoma with several
T2-bright lesions. (Right) Axial
T2WI FSE MR of the pelvis lower
down again shows the grape-
like cluster/botryoid-like nature
of the vaginal embryonal
rhabdomyosarcoma with T2
cystic spaces with intervening
septations, a classic feature of
this tumor.

a 2 year old with botryoid type
embryonal rhabdomyosarcoma
shows the typical grape-like
cluster configuration of the
mass. (Right) Coronal T1 C+
subtraction MR image shows
marked enhancement of the
embryonal rhabdomyosarcoma.
Note the mass protruding into
the introitus .

shows complete replacement
of the uterus and vagina
by botryoid-like soft tissue
in this 2 year old with
embryonal rhabdomyosarcoma.
MR in the same 2-year-old
girl with botryoid embryonal
diffuse involvement of the uterus
and vagina by the grape-like
cluster of tumor.
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Key Facts
• Yolk sac tumor (YST): Primary malignant germ cell • YSTs display cellular structures that resemble those of
tumor of vagina primitive yolk sac (vitelline elements)
• Synonym: Endodermal sinus tumor • Serum α-fetoprotein (AFP) is elevated
• Solid mass arising from and expanding vagina • Vaginal YST accounts for 7% of all YSTs
• Most cases are limited to vagina • Occurs primarily in infants
• Bulky vaginal YST may cause vaginal outlet obstruction o Almost exclusively in children < 3 years old
and result in distension of uterus (hydrometra) due to • Patients present with vaginal bleeding/discharge
accumulation of uterine and cervical secretions • Polypoidal friable mass protruding from vagina
• MR is best modality to evaluate local invasion • Extremely chemosensitive
• Chest CT is indicated for evaluation of lung metastases o Cisplatin, etoposide, and bleomycin (PEB)
chemotherapy alone has resulted in complete
• Embryonal rhabdomyosarcoma
remission per recent reports, leaving surgical
intervention as a last resort
• Clear cell carcinoma of vagina
(Left) Axial translabial

pelvic ultrasound in a 15-
month-old girl shows a large
. (Right) Axial PDWI MR
lobulated vaginal mass
with necrotic areas of low
signal intensity .
(Left) Sagittal T1WI MR in the

same patient shows a large
solid mass arising from the
vagina. (Right) Sagittal T1WI
C+ MR in the same patient
shows avid heterogeneous
enhancement of the solid
vaginal mass , which
contains multiple areas of
necrosis .
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Abbreviations Embryonal Rhabdomyosarcoma
• Yolk sac tumor (YST) • More common than YST, similar presentation
Synonyms • Wider age of presentation ranging from 0.1-12.5 years
o Median age: 3.7 years
• Endodermal sinus tumor • Characteristic grape-like clusters in sarcoma botryoides
Definitions • Soft tissue homogeneous mass with occasional
• Primary malignant germ cell tumor of vagina calcification
o YST shows more heterogeneous enhancement with
irregular margins
IMAGING
Clear Cell Carcinoma of Vagina
General Features • Usually occurs in adolescence and has not been
• Best diagnostic clue reported in patients under 6 years of age
o Solid mass arising from and expanding vagina
o Almost exclusively in girls < 3 years old
• Location
PATHOLOGY
o Most cases of vaginal YSTs are limited to vagina General Features
▪ Few reports of cervical involvement • Etiology
• Morphology o Aberrant migration of germ cells during early
o Bulky vaginal YST may cause vaginal outlet embryonic life has been implicated as possible origin
obstruction and result in distension of uterine cavity • Associated abnormalities
(hydrometra) due to accumulation of uterine and o Raised serum α-fetoprotein (AFP)
cervical secretions ▪ AFP serum level correlates with tumor volume
CT Findings o Serum AFP levels should be used as a guide to
• Mixed attenuation with irregular margins monitor therapy as well as to detect a recurrence
• Heterogeneous enhancement Gross Pathologic & Surgical Features
MR Findings • Polypoid or sessile soft tan or white vaginal mass
• T1WI • 1-5 cm in diameter
o Uniformly isointense relative to muscle Microscopic Features
• T2WI • YSTs display cellular structures that resemble those of
o Heterogeneously hyperintense relative to muscle primitive yolk sac (vitelline elements)
o May show areas of necrosis, especially if large • Term YST is more inclusive than original term,
• DWI endodermal sinus tumor, and more suited to describe
o Hyperintense (at b value of 800 s/mm²) different microscopic patterns observed in this tumor
• T1WI C+ o Variety of histological patterns including
o Heterogeneously enhancing on contrast-enhanced microcystic, reticular, papillary, and solid types
images ▪ Similar to ovarian YST, which is much more
common
Ultrasonographic Findings • Schiller-Duval bodies are characteristic
• Transperineal or translabial ultrasound should be used o Composed of isolated papillary projections with
for evaluation of possible vaginal masses a central blood vessel and peripheral sleeve of
o Transvaginal ultrasound should never be performed
•
embryonic epithelial cells
Homogeneous pelvic soft tissue mass o Presence of Schiller-Duval bodies is considered
o Inferior to uterus and cervix diagnostic of YST
o Posterior to bladder ▪ In some tumors, they may be poorly represented,
Imaging Recommendations atypical, or absent
▪ Their absence does not preclude diagnosis of YST if
• Best imaging tool appearance of tumor is otherwise typical
o US is modality of choice for screening of symptoms
o MR is best modality to evaluate local invasion • Extracellular hyaline droplets common
o PAS-positive, diastase-resistant hyaline globules with
▪ Tumor may approximate bladder anteriorly and
rectum posteriorly with loss of fat planes intracytoplasmic AFP immunopositivity and LEU-M1
▪ Can be difficult to delineate from uterus and immunonegativity
cervix, and may extend into uterus and fallopian ▪ Hyaline globules in clear cell carcinomas are
tubes PAS-positive, diastase-sensitive (glycogen), AFP
o Chest CT is warranted for evaluation of lung immunonegative, and LEU-M1 positive
metastases • Positive for AFP, α-1-antitrypsin (A1AT), cytokeratin,
and placental alkaline phosphatase
• Negative for beta subunit of human chorionic
gonadotropin (hCG-β)
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• Due to clear cell morphology, YST is often SELECTED REFERENCES

misdiagnosed as clear cell adenocarcinoma
1. Goyal S et al: Endodermal sinus tumor of vagina posing a
diagnostic challenge and managed by chemotherapy and
CLINICAL ISSUES novel posterior sagittal surgical approach: lessons learned. J
Obstet Gynaecol Res. 40(2):632-6, 2014
Presentation 2. Sudour-Bonnange H et al: Germ cell tumors in atypical
• Most common signs/symptoms locations: experience of the TGM 95 SFCE trial. J Pediatr
o Vaginal bleeding/discharge Hematol Oncol. 36(8):646-8, 2014
o Polypoidal friable mass protruding from vagina 3. Chauhan S et al: Endodermal sinus tumor of vagina in
infants. Rare Tumors. 5(2):83-4, 2013
▪ Many cases are misdiagnosed as sarcoma 4. Liu QY et al: Clinical manifestations and MRI features of
botryoides vaginal endodermal sinus tumors in four children. Pediatr
o Mass effect on bladder, ureters, or urethra Radiol. 43(8):983-90, 2013
▪ May lead to bladder outlet obstruction &/or 5. Arafah M et al: A case of yolk sac tumor of the vagina in an
hydroureter and hydronephrosis infant. Arch Gynecol Obstet. 285(5):1403-5, 2012
6. Dhanasekharan A et al: Endodermal sinus tumor of the
Demographics vagina in a child. J Obstet Gynaecol India. 62(Suppl 1):81-2,
• Age 2012
o Occurs primarily in infants 7. Mardi K et al: Primary yolk sac tumor of cervix and vagina
▪ Almost exclusively in children < 3 years old in an adult female: a rare case report. Indian J Cancer.
48(4):515-6, 2011
▪ Average age of presentation is 10 months
8. Wani NA et al: Vaginal yolk sac tumor causing infantile
o Rare case reports in adults
•
hydrometra: use of multidetector-row computed
Epidemiology tomography. J Pediatr Adolesc Gynecol. 23(3):e115-8, 2010
o Very rare 9. Watanabe N et al: Vaginal yolk sac (endodermal sinus)
▪ ~ 100 cases have been reported in English language tumors in infancy presenting persistent vaginal bleeding. J
literature Obstet Gynaecol Res. 36(1):213-6, 2010
o Vaginal YST accounts for 7% of all YSTs 10. Gangopadhyay M et al: Endodermal sinus tumor of the
vagina in children: a report of two cases. Indian J Pathol
Natural History & Prognosis Microbiol. 52(3):403-4, 2009
• Highly malignant germ cell tumor 11. Mahzouni P et al: Yolk sac tumor of the vagina. Saudi Med J.
28(7):1125-6, 2007
o Locally aggressive and capable of metastasis via
12. Deshmukh C et al: Yolk sac tumor of vagina. Indian J
hematogenous and lymphatic pathways Pediatr. 72(4):367, 2005
o Untreated patients have died within 2 to 4 months of 13. Kumar V et al: Vaginal endodermal sinus tumor. Indian J
presentation Pediatr. 72(9):797-8, 2005
• Extremely chemosensitive 14. Chatterjee U et al: Endodermal sinus tumor of vagina. J
• Current survival rate for genital malignant germ cell
15.
Indian Assoc Pediatr Surg. 8:235-8, 2003
Grygotis LA et al: Endodermal sinus tumor of the vagina.
tumors is excellent
AJR Am J Roentgenol. 169(6):1632, 1997
o 4-year event-free survival rate
16. Imai A et al: Endodermal sinus tumor of the vagina in an
▪ 76.2 ± 13.1% infant: magnetic resonance imaging evaluation. Gynecol
o 4-year overall survival rate Oncol. 48(3):402-5, 1993
▪ 91.7 ± 8.4%
Treatment
• Cisplatin, etoposide, and bleomycin (PEB)
chemotherapy alone has resulted in complete
remission according to recent reports, leaving surgical
intervention as a last resort
• Partial vaginectomy to eradicate tumor, followed by
chemotherapy
o Preferred over local tumor excision, which carries a
high risk of local recurrence
• Radical surgery is unwarranted
o May be required in patients with advanced local
disease and tumor infiltration into surrounding
structures, cervix, and uterus
• Imaging features are nonspecific; final diagnosis is
based on histology and raised AFP
o AFP measurement is essential in a very young female
presenting with vaginal tumors
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(Left) Sagittal T2WI MR in a 17-
month-old girl who presented
with vaginal bleeding shows
a slightly heterogeneous
hyperintense mass expanding
the vagina. (Right) Axial T2WI
slightly heterogeneous lobulated
hyperintense mass (relative
to pelvic skeletal muscles)
expanding the vagina. There
is no invasion of the urinary
bladder or rectum.

patient shows a homogeneous
lobulated mass expanding the
vagina. The mass is isointense
to the pelvic skeletal muscles.
(Right) Axial T1WI FS MR in the
same patient shows 2 enlarged
right side pelvic lymph nodes
showing similar signal intensity
to the vaginal mass and to pelvic
skeletal muscles.

of the vaginal mass .
the right side pelvic lymph nodes
. Vaginal yolk sac tumors
are aggressive tumors that may
show invasion of local pelvic
structures and nodal and distant
metastases.
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Key Facts
Imaging o 40% are squamous cell carcinomas
o 10-20% are adenoid cystic carcinoma
• Soft tissue mass in region of Bartholin gland o Remaining are transitional cell carcinomas,
o Persistent nonhealing abscess
o Vulvar extension adenosquamous carcinomas, and neuroendocrine
o Posterolateral 1/3 of vagina, medial to labia minora tumors (e.g., Merkel cell carcinoma)
• Paravaginal/periurethral position Clinical Issues
• CT • Solid nodules, often misdiagnosed as Bartholin gland
o Enhancing soft tissue mass in region of Bartholin cyst or abscess, which results in delayed treatment
gland • Painless lump in posterior 1/2 of vulva, pruritus,
• MR bleeding
o T2WI: High signal intensity • Overlying skin intact
o T1WI C+: Enhancing mass • Radical vulvectomy with inguinofemoral
• Local lymphadenopathy/vulvar extension of tumor lymphadenectomy
Pathology • ≤ 2 cm and not midline extension → ipsilateral

lymphadenectomy adequate
• Reported association with high-risk human papilloma • ≥ 2 cm or midline extension → bilateral
virus (HPV) subtypes (e.g., HPV-16), squamous cell inguinofemoral lymphadenectomy and adjuvant
carcinoma, & transitional cell carcinoma (chemo) radiation

in the vulva in a 76-year-
with persistent perineal
drainage shows a lobulated
isointense mass with
cystic change replacing
the right Bartholin gland.
Pathology proved to be
squamous cell carcinoma of
the Bartholin gland. (Right)
Axial T2WI FSE MR lower in
the vulva in the same patient
shows the primary Bartholin
gland carcinoma , tumor
extension, and involvement of
the right labia .

a patient with Bartholin gland
carcinoma shows marked
enhancement of the primary
tumor with regions of
necrosis and extension into
the vulva including the right
labia. (Right) Coronal T1 C+
FS MR centered in the pelvis
coronal extent of the soft tissue
and necrotic mass of
the Bartholin gland.
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TERMINOLOGY • Rest are transitional cell carcinomas, adenosquamous
carcinomas, and neuroendocrine tumors (e.g., Merkel
Definitions cell carcinoma)
• Carcinoma of Bartholin gland
CLINICAL ISSUES
General Features • Most common signs/symptoms
• Best diagnostic clue o Solid nodules, often misdiagnosed as Bartholin gland
o Soft tissue mass in region of Bartholin gland cyst or abscess, which results in delayed treatment
▪ Persistent nonhealing abscess o Painless lump in posterior 1/2 of vulva, pruritus,
▪ Vulvar extension bleeding
• Location o Overlying skin intact
o Posterolateral 3rd of vagina, medial to labia minora Demographics
o Paravaginal/periurethral position
• Age
CT Findings o Average: 60 years
• Enhancing soft tissue mass in region of Bartholin gland Natural History & Prognosis
MR Findings • Prior bartholinitis or abscess in ~ 7% of patients
• T1WI: Intermediate signal intensity • 5-year survival
• T2WI: High signal intensity o Negative inguinal femoral nodes: 52-89%
o Positive inguinal nodes: 18-20%
• T1WI C+: Enhancing mass
• Local lymphadenopathy/vulvar extension of tumor Treatment
Ultrasonographic Findings • Radical vulvectomy with inguinofemoral
• Soft tissue mass in region of Bartholin gland lymphadenectomy
o ≤ 2 cm and not midline extension → ipsilateral
• Enlarged inguinal lymph nodes may be present lymphadenectomy adequate
Imaging Recommendations o ≥ 2 cm or midline extension → bilateral
• Best imaging tool inguinofemoral lymphadenectomy and adjuvant
(chemo) radiation
o MR
• Protocol advice
o MR is useful in treatment planning DIAGNOSTIC CHECKLIST
o MR and CT are useful in evaluating deep pelvic
lymph nodes and distant metastases Image Interpretation Pearls
• Enhancing, heterogeneous soft tissue mass replacing
Bartholin gland
Bartholin Gland Cyst or Abscess SELECTED REFERENCES
• Cystic mass located within Bartholin gland 1. Kajal B et al: Apocrine adenocarcinoma of the vulva. Rare
Tumors. 5(3):e40, 2013
Gartner Duct Cyst
• Cyst located paravaginally
2. Ouldamer L et al: Bartholin's gland carcinoma:
epidemiology and therapeutic management. Surg Oncol.
22(2):117-22, 2013
Vulva Carcinoma
• Solid mass located in vulva
3. Scurry JP et al: Unusual locations of primary subepithelial
squamous cell carcinomas of the vulva. J Low Genit Tract
Dis. 17(4):e8-e11, 2013
4. Hosseinzadeh K et al: Imaging of the female perineum in
PATHOLOGY adults. Radiographics. 32(4):E129-68, 2012
5. Ng SM et al: Bartholin's gland squamous cell carcinoma. J
General Features
• Etiology
6. Jiménez-Ayala M et al: Glandular lesions of the vulva.
o Reported association with high-risk human Monogr Clin Cytol. 20:77-86, 2011
papilloma virus (HPV) subtypes (e.g., HPV-16), 7. Khanna G; Rajni et al: Bartholin gland carcinoma. Indian J
squamous cell carcinoma, and transitional cell Pathol Microbiol. 53(1):171-2, 2010
carcinoma 8. Nayak AU et al: Wolf in lamb's skin: Vulval carcinoma
mimicking bartholin gland abscess. Indian J Sex Transm Dis.
30(1):46-7, 2009
o Bartholin gland abscess 9. Wydra D et al: The problem of accurate initial diagnosis of
Bartholin's gland carcinoma resulting in delayed treatment
• 40% are squamous cell carcinomas
and aggressive course of the disease. Int J Gynecol Cancer.
16(3):1469-72, 2006
• Mucinous tumors express carcinoembryonic antigen
(CEA) and CA19-9
• 10-20% adenoid cystic carcinoma
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(T) Primary Tumor
T1a IA Lesions ≤ 2 cm in size, confined to vulva or perineum and with stromal invasion ≤ 1.0
mm²
T1b IB Lesions > 2 cm in size or any size with stromal invasion > 1.0 mm, confined to vulva or
perineum
T2³ II/III Tumor of any size with extension to adjacent perineal structures (lower/distal 1/3 urethra,
lower/distal 1/3 vagina, anal involvement)
T3⁴ IVA Tumor of any size with extension to any of the following: Upper/proximal 2/3 of urethra,
upper/proximal 2/3 vagina, bladder mucosa, rectal mucosa, or fixed to pelvic bone

N1 1 or 2 regional lymph nodes with the following features
N1a IIIA 1 or 2 lymph node metastases each < 5 mm
N1b IIIA 1 lymph node metastasis ≥ 5 mm
N2 IIIB Regional lymph node metastasis with the following features
N2a IIIB ≥ 3 lymph node metastases each < 5 mm
N2b IIIB ≥ 2 lymph node metastases ≥ 5 mm
N2c IIIC Lymph node metastasis with extracapsular spread
N3 IVA Fixed or ulcerated regional lymph node metastasis

M1 IVB Distant metastasis (including pelvic lymph node metastasis)
¹FIGO no longer includes stage 0 (Tis). ²The depth of invasion is defined as the measurement of the tumor from the epithelial-
stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion. ³FIGO uses the classification
T2/T3. This is defined as T2 in TNM. ⁴FIGO uses the classification T4. This is defined as T3 in TNM.

Stage T N M
0 Tis N0 M0
I T1 N0 M0
IA T1a N0 M0
IB T1b N0 M0
II T2 N0 M0
IIIA T1, T2 N1a, N1b M0
IIIB T1, T2 N2a, N2b M0
IIIC T1, T2 N2c M0
IVA T1, T2 N3 M0
T3 Any N M0
IVB Any T Any N M1
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Tis Tis
Low-power magnification of an H&E section from a vulvar biopsy Higher magnification shows the crowded, pleomorphic, and
specimen shows the surface of the stratified squamous epithelium. dysplastic cells that lack maturation. The nuclei are hyperchromatic
Deep to the surface is the intraepithelial lesion characterized by with many mitotic figures . Note that the basement membrane
cellular disarray with lack of maturation that involves almost the full is intact with no invasive component.
thickness of the epithelium .
T1a T1a
H&E stain of a biopsy specimen from an ulcerated skin lesion Higher magnification shows invasion of squamous cords and nests
shows invasive squamous cell carcinoma with superficial stromal into the superficial dermis. Note the keratinized nest on the right
invasion of < 1 mm depth. Note 0.7 mm depth of invasion . side .
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T1b T1b
Low magnification of H&E stain from vulvar biopsy specimen Higher magnification of the invasive component shows
shows overlying stratified squamous epithelium with an invasive nonkeratinized cords and nests of malignant cells in a desmoplastic
squamous cell carcinoma infiltrating to a depth of 3 mm. stroma.
T3 T3
H&E stain of a biopsy specimen from the urinary bladder shows Higher magnification image depicts transitional epithelium
bladder mucosa with transitional epithelium . Invasive vulvar with squamous cell carcinoma of vulvar primary in close
carcinoma involves the wall of the bladder and extends to approximation.
involve the bladder mucosa in the left upper corner .
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T1a T1b
External view of the female genitalia depicts tumor confined to External view of the female genitalia depicts tumor confined to
the vulva or vulva and perineum measuring ≤ 2 cm in greatest the vulva, or vulva and perineum, measuring > 2 cm in greatest
dimension. In addition, depth of tumor invasion must be ≤ 1 mm dimension. In addition, tumor of any size with depth of invasion > 1
for tumor stage T1a. mm is stage T1b.
T2 T2
External view of the female genitalia depicts tumor extending to Sagittal view of the pelvis depicts vulvar tumor invading the lower
adjacent perineal structures. T2 tumors can be any size while urethra, lower vagina, and anus. Invasion of the distal 1/3 of
invading the lower urethra, lower vagina, and anus. adjacent perineal structures characterizes tumor stage T2.
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T3 T3
Sagittal view of the pelvis depicts vulvar tumor extending to the Sagittal view of the pelvis depicts vulvar tumor invading the rectum.
upper urethra, urinary bladder, and pubic bone. Invasion of the Extension to the rectal mucosa constitutes tumor stage T3.
proximal urethra and bladder mucosa constitutes tumor stage T3, as
does tumor fixed to the pelvic bone.
N1a and N1b N2a and N2b
Graphic shows the inguinofemoral lymph node basin. Image on the Image on the left depicts 3 lymph node metastases, each < 5 mm.
left depicts 1 lymph node metastasis ≤ 5 mm. Only 1 or 2 regional For nodal stage N2a, ≥ 3 regional lymph nodes with metastases <
lymph nodes with metastases ≤ 5 mm can be involved for nodal 5 mm can be involved. Image on the right depicts 2 lymph node
stage N1a. Image on the right depicts 1 lymph node metastasis ≥ 5 metastases ≥ 5 mm. For nodal stage N2b, 2 or more lymph nodes
mm, which constitutes stage N1b. with metastases ≥ 5 mm can be involved.
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Vagina and Vulva

N2c N3
Graphic shows the inguinofemoral lymph node basin with a Graphic of the inguinofemoral lymph node basin depicts regional
magnified lymph node inset. Regional lymph node metastases with lymph node metastases with the nodal mass fixed to surrounding
extracapsular spread of tumor constitute nodal stage N2c. tissues. Fixation or ulceration of adjacent tissues constitutes nodal
stage N3.

Pelvic lymph nodes
Intraabdominal sites
Lung
Bone
Central nervous system
Distant metastatic disease beyond the pelvic lymph nodes is

rare. The number is not sufficiently significant to determine
organ frequency.
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▪ 1.1-2 mm → 5.4%
OVERVIEW ▪ > 5 mm → 32%
o Other patterns of lymphatic spread
General Comments
▪ Bilateral groin metastasis
• 4th most common gynecologic malignancy
– Drainage from midline structures: Perineum and
• 5% of female genital tract malignancies
clitoris
• 90% are squamous cell carcinoma
▪ Contralateral groin metastasis
Classification – Bartholin cancer
• Histopathologic types ▪ Direct spread to pelvic nodes
o Squamous cell carcinoma – Rarely occurs with central cancers
o Verrucous carcinoma – Direct drainage via internal pudendal chain to
o Paget disease of vulva internal iliac nodes
o Adenocarcinoma, not otherwise specified (NOS) ▪ Subcutaneous and dermal lymphatics
o Basal cell carcinoma, NOS – Obstruction of typical lymphatic drainage
o Bartholin gland carcinoma – Involves vulva, upper thighs, lower abdomen
• Mucosal malignant melanoma is not included in this ▪ Obturator or internal iliac nodes
classification and staging – Involved if invasion of vagina or bladder
o Risk factors for lymph node metastases
▪ Clinical node status
PATHOLOGY ▪ Age
▪ Degree of differentiation
Routes of Spread ▪ Tumor stage
• Contiguous spread ▪ Tumor thickness
o Influenced by histology ▪ Depth of stromal invasion
▪ Well differentiated: Superficial spread with ▪ Presence of lymphovascular invasion
minimal invasion • Hematogenous spread
▪ Anaplastic: More likely to be deeply invasive o Distant metastases are rare and usually fatal
o Posteriorly to anus and rectum o Most common to lungs
o Anteriorly to urethra, rarely to urinary bladder and o Occur late and rarely without nodal metastases
pubic bone o 1 series showed significantly lower risk of
o Cranially to vagina hematogenous metastases with < 3 positive lymph
o Usually slowly infiltrates local tissues, followed by nodes at time of diagnosis
lymph node spread
General Features
o Typical lymphatic drainage • Comments
o 5-8% of gynecologic malignancies
▪ Superficial inguinal lymph nodes
o 4th most common gynecologic malignancy
– Superficial medial: Above and medial to femoral
vein, medial to saphenous vein; comprise largest
• Genetics
o S-phase fraction (proliferation index)
percent of sentinel nodes
▪ ↑ in tumors from patients with lymphatic spread
– Superficial intermediate: Near saphenofemoral
o HPV-encoded oncoproteins E6 and E7
junction
– Superficial lateral: Outer third of groin ▪ Can bind tumor suppressor gene products (p53
▪ Deep femoral lymph nodes protein and retinoblastoma)
– Medially along femoral vein, within femoral ▪ Loss of growth suppression
o Epidermal growth factor receptor
sheath
– Can contain tumor without superficial inguinal ▪ ↑ expression in vulvar tumor is associated with
adenopathy nodal metastases and ↓ patient survival
o HER-2/neu
▪ External iliac lymph nodes
– Cloquet node: Most caudal lymph node in this ▪ Positive → ↑ risk of nodal metastases
chain, at entrance of femoral canal • Etiology
– Cloquet node signals likelihood of pelvic node o Risk factors
metastases ▪ Cigarette smoking
o Drainage based on tumor location ▪ Vulvar dystrophy
▪ Lateral lesions spread to ipsilateral lymph nodes ▪ Vulvar intraepithelial neoplasia (VIN)
– 2.5% spread to contralateral nodes in absence of ▪ Cervical intraepithelial neoplasia (CIN)
ipsilateral metastases ▪ Human papillomavirus infection
▪ Central lesions may spread to ipsilateral, ▪ Immunodeficiency syndromes
contralateral, or both lymph nodes ▪ History of cervical cancer
– Lesions within 1 cm of vulvar midline ▪ Northern European ancestry
– Anterior lesions (area immediately posterior to o Human papilloma virus (HPV)
clitoris) ▪ HPV 16, 18, and 33 are most common
o Likelihood of lymphatic spread increases with each ▪ Responsible for 60% of vulvar cancers
millimeter of depth of invasion ▪ ↑ incidence of HPV(+) vulvar tumors (VIN &
4 ▪ ≤ 1 mm → 0% invasive cancer)
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▪ HPV-related cancer found in younger women (< 60 ▪ Contrast-enhanced imaging may help with tumor
years) detection, but may overestimate tumor size
– Tend to present with earlier stage disease
– Tend to be multifocal Staging
– May be associated with similar lesions of cervix • Surgically staged malignancy
and vagina • Stage cannot be changed on basis of disease
o Vulvar dystrophies progression, response, or recurrence
▪ Includes lichen sclerosus and squamous cell • Primary tumor
o Vulva is composed of the following structures
hyperplasia
▪ Not associated with HPV ▪ Labia majora and minora
▪ Cancer occurs in older women (> 60 years) ▪ Vestibule of vagina
▪ Typically unifocal and well differentiated ▪ Opening of urethra
• Epidemiology & cancer incidence ▪ Clitoral glans, body, crura
o 4,700 estimated new cases in USA in 2013 ▪ Bulbospongiosus and ischiocavernosus muscles
o 990 estimated deaths in USA in 2013 ▪ Bulbs of vestibule
o Rate of invasive cancer has been stable for 2 decades o Imaging is of limited utility in early stage (small
o Incidence of VIN (in situ) has doubled superficial) tumors
o CT
• Associated diseases, abnormalities
o Synchronous 2nd malignancy in up to 22% ▪ May show gross invasion of adjacent structures
▪ Most commonly cervical neoplasia ▪ Limited for depth of invasion and tumor size
o MR
Gross Pathology & Surgical Features ▪ Accuracy 70-85%
• Location ▪ May be helpful for deeply invading tumor
o 50% in labia majora ▪ May help evaluate invasion of adjacent structures
o 15-20% in labia minora ▪ T2WI are most useful for extent of tumor
o 10-15% in clitoris ▪ Vaginal gel may help
o Infrequently in other sites (Bartholin glands) • Lymphatic metastasis
• 10% of lesions are too extensive to determine site of o Regional lymph nodes → superficial inguinal and
origin deep femoral nodes
• 5% of cases are multifocal o Likelihood of lymphatic spread is very low if ≤ 1 mm
• Verrucous cancer is typically exophytic stromal invasion
o May be large, infiltrates locally o Unilateral lesions with ≥ 3 mm stromal invasion
have ≥ 2.8% rate of bilateral groin metastases
Microscopic Pathology o Traditionally nodal staging has been surgical
• H&E ▪ Inguinal-femoral lymphadenectomy
o Squamous cell carcinoma is most common
▪ Up to 70% of patients have node-negative disease
o Usually well differentiated
▪ Incur undue morbidity of surgical dissection
o If high grade, may have areas of glandular
– Lower extremity lymphedema (most common,
differentiation
o Clitoral tumors may be more anaplastic in up to 69%)
– Wound breakdown or infection
o VIN and keratosis may occur at margins
– Lymphocysts
▪ Better prognosis
– Psychosexual consequences
o Fibromyxoid stromal response
o Unilateral dissection performed if < 1% risk of
▪ Older age
contralateral metastasis
▪ Worse survival rates
▪ Unifocal tumor < 2 cm
▪ More extensive nodal metastases
▪ Lateral lesion (> 1 cm from vulvar midline)
▪ No palpable adenopathy in either groin
▪ No nodal metastases at time of unilateral LND
IMAGING FINDINGS o Bilateral dissection performed if
▪ Tumor > 2 cm
Detection ▪ Central lesion (< 1 cm from vulvar midline)
• Ultrasound ▪ Metastases found at unilateral LND
o No role in primary tumor detection
o Clinical palpation is unreliable
• CT ▪ Sensitivity is 57%, specificity is 62%
o Small superficial tumors often not seen
▪ Allows evaluation of only superficial lymph nodes
▪ May appear as irregularity of vulvar surface
▪ May be limited by body habitus, small lymph node
o Large exophytic tumors
size, scar tissue
▪ Exophytic enhancing solid mass o Ultrasound
▪ Surface irregularity may indicate ulceration
▪ Helpful for evaluation of groin adenopathy
• MR – Sensitivity is 86%, specificity is 96%
o Limited for small tumors and plaque-like lesions
▪ Characteristics of malignant lymph nodes
o Tumor characteristics
– Round shape, irregular contour
▪ Hypointense on T1WI
– Short axis diameter > 8 mm
▪ Intermediate to high signal on T2WI
– Long axis:short axis ratio < 2
– Loss of echogenic fatty hilum 4
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– ↑ thickness and ↓ echogenicity of cortex ▪ Metastases in ≥ 2 groin nodes

– Peripheral vascularity, high-resistance flow o Location
▪ Advantages ▪ Perineum: 43-54%, may be amenable to reexcision
– Can evaluate superficial and deep lymph nodes ▪ Groin: 6-30%, develop sooner than local relapses,
– Can guide surgery or cytology ominous prognosis
▪ Limitations ▪ Skin bridge (between vulvar and groin incisions)
– Operator dependent ▪ Pelvic lymph nodes
– May be difficult to reproduce findings ▪ Distant sites: 8-23%, dismal prognosis
– False-positives due to reactive lymph nodes
– Morphologically normal lymph nodes may
harbor micrometastases CLINICAL ISSUES
o US-guided fine-needle aspiration cytology
▪ Most reliable: Combines morphology and cytology Presentation
– Sensitivity is 93%, specificity is 100% • Elderly women, mean age of 65 at diagnosis
▪ More sensitive than cytology alone o Data suggest age at diagnosis is trending down
– Sensitivity of 75% due to sampling error ▪ May be related to ↑ in VIN in young women
▪ Limitations • Signs and symptoms
– Operator dependent o Asymptomatic
– Micrometastases o Pruritus, bleeding or discharge, dysuria
o CT o Vulvar plaque, ulcer, or mass
▪ Inferior to US and guided FNA in detecting o Enlarged groin lymph node
malignant adenopathy
▪ Can identify deep pelvic and retroperitoneal Cancer Natural History & Prognosis
lymph node metastases • Lymph nodes are most important prognostic indicator
o MR o 90% survival if negative regional nodes
▪ Malignant lymph node characteristics o 50-60% survival if positive regional nodes
– Short axis diameter > 10 mm (sensitivity 89%, o Extracapsular spread is most valuable lymph node-
specificity 91%) associated prognostic factor
– Irregular or round shape, spiculated contour ▪ Overall survival when metastasis is confined to
– Short axis:long axis ratio ≥ .75 (sensitivity 87%, nodes 66%, but with extranodal spread 34%
o Node number and size may alter prognosis as they
specificity 81%, accuracy 85%)
– Central necrosis (sensitivity 38%, specificity reflect tumor burden, but may not be independent
93%) prognostic indicators
▪ Advantages o Bilateral lymph node metastases
– Not operator dependent and reproducible ▪ Previously thought to be independent prognostic
– Multiplanar imaging allows assessment of size, factor
shape, and signal intensity ▪ When adjusted for number of nodes, no significant
– Can identify deep pelvic and retroperitoneal influence on prognosis
lymph node metastases ▪ May alter treatment
o PET • Tumor characteristics are important in prognosis
▪ Sensitivity 80% and specificity 90% for nodal o Tumor size
metastases ▪ May be important independent prognostic factor
▪ Limitations in node negative cases
– False-positives (acute or chronic inflammation, o Depth of tumor invasion
post-radiotherapy reactions) ▪ Measured from epithelial-stromal junction of
– False-negatives (micrometastases, necrotic adjacent most superficial dermal papilla to deepest
nodes, mucinous tumor) point of invasion
o Lymphovascular space invasion
• Distant metastasis
o Any site beyond regional lymph nodes, including ▪ Documented at histologic evaluation
external iliac and pelvic nodes ▪ Correlates with incidence of nodal metastases
▪ Lung, extragenital skin, bone, intraabdominal Treatment Options
sites, heart, central nervous system
o Rare in most common types of vulvar cancer
• Major treatment alternatives
o Surgery
o Can be seen with melanoma and rare sarcomas
▪ Radical vulvectomy
Restaging – Removal of vulva to level of deep thigh fascia
• Recurrence – Removal of periosteum of pubis
o Poor prognosis, usually fatal – Removal of inferior fascia of urogenital
o 10-15% of surgically treated patients diaphragm
o 80% of recurrence occurs within 2 years of primary ▪ Radical local excision with 1 cm margin has nearly
treatment replaced radical vulvectomy
o Predictors of recurrence ▪ Inguinofemoral lymphadenectomy
▪ Size of lesion – Separate groin incisions have replaced en bloc
resection with vulvectomy due to ↓ morbidity
4 ▪ Close margins at resection
– Need > 10 mm tumor-free margin – Chronic lymphedema reported in up to 69%
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o Radiation therapy
▪ Primary radiation therapy REPORTING CHECKLIST
– Unable to tolerate surgery
▪ Adjuvant radiation therapy
T Staging
– Surgical margin < 8 mm, lymphovascular
• Size
invasion, > 5 mm thickness
• Depth of invasion
– Radiation therapy to groin if node positive
• Invasion of adjacent structures
o Urethra: Lower or upper
▪ Neoadjuvant radiation therapy o Urinary bladder
– May be used in advanced stage disease to o Vagina: Lower or upper
improve operability and decrease extent of o Anus
surgery o
o Sentinel node biopsy (SNB) and mapping Rectal mucosa
o Pubic bone
▪ Injection of dye/radiotracer within/around lesion
▪ Sentinel node = 1st draining node N Staging
– Pathologic status is considered to represent all • Location
lymph nodes in a lymphatic basin o Superficial inguinal
▪ Detection rate of 96.2% with combination of dye o Deep femoral
and radiotracer methods • Morphology
▪ Performed in cases without clear nodal metastases o Size and shape
clinically or on imaging o Fatty hilum and cortex
▪ False-negatives: Node completely replaced by o Vascularity
tumor or lymphatic stasis • Extracapsular spread
▪ Poor candidates for SNB: Multifocal tumors, large • Fixed or ulcerated
tumors, history of prior chemoradiation • Unilateral or bilateral
• Treatment options by stage
o Early stage disease M Staging
▪ Microinvasive disease (< 1 mm invasion) • Pelvic lymph nodes
– Wide excision (5-10 mm) • Distant metastasis
▪ Lateralized tumor confined to vulva < 2 cm,
invasion < 5 mm, clinically node negative
– Radical local excision SELECTED REFERENCES
– Sentinel node biopsy ± unilateral lymph node
1. National Cancer Institute: http://www.cancer.gov/
dissection (LND) cancertopics/pdq/treatment/vulvar/HealthProfessional.
▪ Tumor confined to vulva and perineum > 2 cm Modified February 2013. Accessed February 8, 2014
– Modified radical vulvectomy 2. Kim KW et al: Update on imaging of vulvar squamous cell
– Sentinel node biopsy ± inguinofemoral LND carcinoma. AJR Am J Roentgenol. 201(1):W147-57, 2013
– Adjuvant local radiation therapy if surgical 3. Viswanathan C et al: Multimodality imaging of vulvar
margin < 8 mm, lymphovascular invasion, > 5 cancer: staging, therapeutic response, and complications.
mm thickness, positive lymph nodes
4. Tabbaa ZM et al: Impact of the new FIGO 2009 staging
▪ If patient is unable to tolerate surgery → radiation classification for vulvar cancer on prognosis and stage
o Advanced stage disease distribution. Gynecol Oncol. 127(1):147-52, 2012
▪ Radical vulvectomy + inguinofemoral LND 5. American Joint Committee on Cancer: AJCC Cancer Staging
– Depending on tumor extent, may require Manual. 7th ed. New York: Springer. 379-86, 2010
removal of involved structures or pelvic 6. Kataoka MY et al: The accuracy of magnetic resonance
exenteration imaging in staging of vulvar cancer: a retrospective multi-
– Radiation therapy to vulva if large tumor, centre study. Gynecol Oncol. 117(1):82-7, 2010
7. McMahon CJ et al: Lymphatic metastases from pelvic
margins narrow, lymphovascular invasion, or tumors: anatomic classification, characterization, and
thickness > 5 mm staging. Radiology. 254(1):31-46, 2010
– Radiation therapy to groin if positive lymph 8. van der Steen S et al: New FIGO staging system of vulvar
nodes → improved survival cancer indeed provides a better reflection of prognosis.
▪ Neoadjuvant radiation or chemoradiation may Gynecol Oncol. 119(3):520-5, 2010
improve operability or decrease extent of surgery 9. Oonk MH et al: The role of sentinel node biopsy in
▪ If patient is unable to tolerate surgery → radiation gynecological cancer: a review. Curr Opin Oncol.
21(5):425-32, 2009
therapy ± chemotherapy 10. Land R et al: Routine computerized tomography scanning,
o Survival mostly determined by lymph node
groin ultrasound with or without fine needle aspiration
metastases cytology in the surgical management of primary squamous
▪ Unilateral lymphadenopathy, 70% 5-year survival cell carcinoma of the vulva. Int J Gynecol Cancer.
▪ ≥ 3 positive unilateral lymph nodes, 30% 5-year 16(1):312-7, 2006
survival 11. Oonk MH et al: Prediction of lymph node metastases in
o Recurrent disease vulvar cancer: a review. Int J Gynecol Cancer. 16(3):963-71,
▪ Local recurrence without regional LND 2006
– Radical excision: 5-year survival is 56%
▪ Local recurrence > 2 years after treatment
– Excision and radiation: 5-year survival > 50%
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Stage IB (T1b N0 M0) Stage II (T2 N0 M0)

(Left) Coronal PET/CT shows
minimal soft tissue and
increased FDG uptake in
the left vulva. No enlarged
or FDG-avid lymph nodes
were seen. On physical
examination, this tumor
was estimated to be 1 x 1
cm; however, on pathologic
examination, the largest
diameter was 2.1 cm, making
it a T1b tumor. (Right)
Coronal T2WI MR shows an
intermediate-signal mass
arising from the labia majora
and extending up to invade
the lower urethra.
Stage II (T2 N0 M0) Stage IIIA (T1b N1b M0)

avid enhancement of the
vulvar mass . No regional
or pelvic adenopathy was
seen on this exam. (Right)
Axial and coronal CECT
images show a right inguinal
lymph node with central
hypodensity. The fatty hilum
is obliterated, and the node
is replaced by soft tissue
centrally. The metastatic focus
is > 5 mm; however, there is
no extracapsular spread of
tumor.
Stage IIIB (T2 N2b M0) Stage IIIB (T2 N2b M0)
shows an enhancing vulvar
mass . (Right) Axial T1WI
shows cephalad extension of
the vulvar mass to invade
the distal urethra. In addition,
there are 2 enlarged, round,
enhancing right inguinal
lymph nodes with loss of
the fatty hila, corresponding
to nodal stage N2b.
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Vagina and Vulva

Stage IIIC (T2 N2c M0) Stage IIIC (T2 N2c M0)
an enhancing vulvar
mass with a large
exophytic component. The
right labia majora is
partially visualized with skin
thickening and enhancement,
concerning for dermal
invasion. (Right) Axial CECT
a large right inguinal lymph
node with foci of central
necrosis . The lymph
node margins are irregular
and ill defined, suggestive of
extracapsular spread.
(Left) Axial T2WI FSE
shows a large, exophytic,
intermediate-signal vulvar
mass . (Right) Axial
T2WI FSE MR obtained
more cephalad to the
previous image shows the
intermediate-signal mass
invading the right lower
vaginal wall and the right
crus of the clitoris, as well as
obliterating the lower urethra.
the large exophytic vulvar
mass. Note extension to the
lower urethra and vagina
MR shows the vulvar mass
invading the lower urethra
. Note the normal, low-
signal upper urethra .
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(Left) Coronal T2WI MR in
the same patient at the level
of the vagina shows partially
exophytic vulvar tumor
extending cephalad to invade
the lower 1/3 of the vagina
MR in the same patient at
the level of the anus and
rectum shows no involvement
by the vulvar mass . The
fat plane between the mass
and anus is preserved.
through the vulvar mass
also shows dermal thickening
and enhancement of the right
labia majora , consistent
with dermal invasion. (Right)
same patient shows multiple,
hyperenhancing right inguinal
lymph nodes. The largest
lymph node has irregular
ill-defined margins, suggestive
of extracapsular spread.
(Left) Image of the pelvis
from whole-body PET shows
the large hypermetabolic
vulvar mass and right
inguinal lymph node .
There was no distant
metastatic disease, including
no pelvic lymphadenopathy.
(Right) Clinical photo of the
perineum of the same patient
shows a large mass centered
in the right labia majora with
extensive surface ulceration
and necrosis.
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VULVAR CARCINOMA
Vagina and Vulva

(Left) Axial NECT shows
a right femoral lymph
node mass . Ill-defined
infiltrative margins and
encasement of the right
femoral vessels are
characteristic of nodal stage
N3 adenopathy. (Right)
Axial PET/CT in the same
patient shows avid FDG
uptake in the right femoral
lymphadenopathy.

enhancing, ill-defined tumor
replacing the urethra .
enhancing, ill-defined mass
replacing the urethra
and invading the base of the
urinary bladder .
with history of vulvar cancer
status post left vulvectomy
shows bulky left external iliac
adenopathy . (Right) Axial
shows necrotic left paraaortic
adenopathy . Pelvic and
abdominal adenopathy is
usually seen with recurrence,
as in this case. The prognosis
is poor and usually fatal.
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Vagina and Vulva VULVAR LEIOMYOSARCOMA
Key Facts
Terminology o > 5 cm in diameter; ≥ 5 mitoses per 10 HPF;
• Most common sarcoma of vulva, arising from smooth infiltrative margins; moderate to severe cytologic
atypia
muscle
• Immunohistochemical stains are positive for smooth
Imaging muscle actin, vimentin, & may be desmin(+)
• Heterogeneously enhancing vulvar mass involving Clinical Issues
labia majora and minora; commonly presents with
central necrosis • Firm vulvar mass
• There may be associated inguinal lymphadenopathy or • ± local pain and ulceration, bleeding
hematogenous metastases • Perimenopausal or postmenopausal women
• Iso- to hyperintense mass with central regions of high • Accounts for 1-3% of vulvar malignancies
signal intensity due to necrosis • Slow-growing neoplasm; ± hematogenous metastases
and inguinal lymphadenopathy
Pathology
• Reported to be estrogen dependent as may increase in • Wide local excision or radical vulvectomy ± bilateral
inguinal lymph node resection
size in pregnancy
• Smooth muscle tumor with ≥ 3 of the following • Adjuvant radiotherapy for high-grade tumor or locally
recurrent low-grade tumors
criteria are considered malignant
• Chemotherapy in metastatic disease

presenting with a palpable
vulvar mass shows a large,
relative T2-isointense mass
replacing the labia with central
regions of hyperintensity ,
corresponding to central
necrosis in this mass proven to
be a vulvar leiomyosarcoma.
(Right) Coronal T2WI FSE
leiomyosarcoma of the vulva
shows the large centrally
necrotic mass centered in
the vulva , replacing the
labia and extending into the
perineum.

shows avid enhancement of
the vulvar leiomyosarcoma
with central regions of necrosis
. (Right) Axial T1WI C+ FS
MR of the same patient with
vulvar leiomyosarcoma shows
the superior extent of the
tumor to involve the posterior
wall of the vagina and left
perineum.
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VULVAR LEIOMYOSARCOMA
Vagina and Vulva

o Reported to be estrogen dependent as may increase in
TERMINOLOGY
size in pregnancy
Definitions
• Vulval sarcoma arising from smooth muscle • Tumors are often ≥ 5 cm at presentation
IMAGING Microscopic Features
• Smooth muscle tumor with ≥ 3 of the following criteria
General Features are considered malignant
• Best diagnostic clue o > 5 cm in diameter, ≥ 5 mitoses per 10 high-power
o Heterogeneously enhancing vulvar mass, commonly fields, infiltrative margins, moderate to severe
presents with central necrosis cytologic atypia
• Location • Immunohistochemical stains are positive for smooth
o Vulva (labia majora/minora) muscle actin, vimentin, and may be positive for desmin
• Size
o Variable: Reported up to 10 cm CLINICAL ISSUES
• Morphology
Presentation
o Vulvar mass with necrosis and ulceration
CT Findings o Firm vulvar mass, ± local pain and ulceration,
• Vulvar mass showing heterogeneous enhancement bleeding
and associated inguinal lymphadenopathy or • Other signs/symptoms
hematogenous metastases o From hematogenous metastases
o Foci of internal gas and necrosis may be present
Demographics
MR Findings
• Age
• T1WI o Perimenopausal or postmenopausal women
o Low to intermediate signal intensity vulvar mass
• Epidemiology
• T2WI o Accounts for 1-3% of vulvar malignancies
o Iso- to hyperintense mass with central T2 o Most common vulval sarcoma
hyperintensity due to necrosis
• T1WI C+ FS Natural History & Prognosis
o Variable heterogeneous enhancement; necrotic • Slow-growing neoplasm; can present with
regions show decreased enhancement hematogenous metastases and inguinal
lymphadenopathy
Ultrasonographic Findings • Grade is important prognostic factor
• Useful for evaluating groin for lymphadenopathy and Treatment
guiding lymph node biopsy
Imaging Recommendations • Wide local excision or radical vulvectomy ± bilateral
inguinal lymph node resection
• Best imaging tool • Adjuvant radiotherapy for high-grade tumor or locally
o MR is most accurate for local staging; CECT and FDG recurrent low-grade tumors
PET/CT to evaluate for distant metastases • Chemotherapy in metastatic disease
• Protocol advice
o Axial T1WI; axial, coronal, sagittal T2WI; axial and
coronal T1WI FS C+ images DIAGNOSTIC CHECKLIST
Consider
DIFFERENTIAL DIAGNOSIS • MR is used for local staging; CECT and FDG PET/CT are
used for assessment of distant metastases
Other Malignant Vulvar Tumors
• Squamous cell carcinoma and mesenchymal tumors; Image Interpretation Pearls
difficult to distinguish from leiomyosarcoma • Heterogeneously enhancing vulvar mass
• Carcinomas have a more infiltrative pattern and do not
appear as well-defined ball-like masses SELECTED REFERENCES
Benign Vulval Conditions 1. Levy RA et al: Smooth muscle neoplasms of the vulva
• Bartholin abscess shows heterogeneous enhancement; masquerading as Bartholin gland duct cysts. Proc (Bayl Univ
Bartholin cyst does not enhance and is high signal on Med Cent). 27(1):25-7, 2014
T2 2. Salehin D et al: Leiomyosarcoma of the vulva. Eur J
Gynaecol Oncol. 33(3):306-8, 2012
3. McKenzie M et al: A rare case of vulval leiomyosarcoma:
PATHOLOGY management and an updated review of the literature. J
General Features 4. Fasih N et al: Leiomyomas beyond the uterus: unusual
• Etiology locations, rare manifestations. Radiographics.
28(7):1931-48, 2008
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Vagina and Vulva VULVAR AND VAGINAL MELANOMA
Key Facts
Terminology o Vaginal metastases
o Vaginal sarcoma
• Subtype of cutaneous melanoma with similar
prognostic and staging factors Pathology
Imaging • Vulvar melanoma is staged according to AJCC TNM
• Infiltrating vulvar or vaginal mass with high signal on system for skin melanoma
• No staging system for vaginal melanoma has been
both T1WI and T2WI
• FDG-18-avid malignancy; PET/CT is useful for lymph demonstrated to be a useful predictor of prognosis
node and distant metastasis staging Clinical Issues
Top Differential Diagnoses • Peak incidence in 6th-7th decade of life, with a median
• Vulvar melanoma age at diagnosis of 66 years
• Vulvovaginal melanoma is a rare disease
o Vulvar squamous carcinoma
o Atypical melanocytic nevus, genital type • Prognosis is poor
o Vulvar metastases • Treated with wide local excision with unilateral
o Merkel cell carcinoma sentinel lymph node evaluation
o Paget disease • 5-year survival rates
• Vaginal melanoma o Vulval melanoma: 24-77%
o Vaginal melanoma: 5-25%
o Vaginal carcinoma

well-defined vulvar mass .
The appearance of vulvar
melanoma on CECT is not
specific. CECT is helpful in
evaluating local tumor spread
and regional adenopathy.
(Right) Axial T1WI MR shows
a well-defined rounded vulvar
mass , which is of high
pelvic skeletal muscles due
to the paramagnetic effect of
melanin. High signal intensity
on T1WI is characteristic of
melanocytic melanomas.
(Left) Composite PET/CT/

CT image (sagittal: Upper
left; coronal: Upper right;
axial: Lower) shows increased
vulvar and vaginal
masses. There is also an
enlarged left pelvic lymph
node with increased
metabolic activity. (Right)
Axial T2WI MR shows a
right-sided vaginal mass
demonstrating high signal
intensity relative to pelvic
skeletal muscles.
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VULVAR AND VAGINAL MELANOMA
Vagina and Vulva

o Typically elevated with flat or mushroom
TERMINOLOGY
appearance; benign condition in young women
Definitions • Vulvar metastases
• Subtype of cutaneous melanoma with similar o Usually from adjacent organs (vagina, anus, urethra)
prognostic and staging factors • Merkel cell carcinoma
o Aggressive cutaneous neoplasm associated with
IMAGING grave prognosis; most patients die within 1 year of
diagnosis from widespread metastatic disease
General Features • Paget disease
• Best diagnostic clue o Usually confined to epithelium; in general very slow
o Infiltrating vulvar or vaginal mass with high signal growing, nonmalignant, or described as carcinoma in
on both T1WI and T2WI situ
• Location o Invasive adenocarcinoma is present in 10-20% of
o Vulvar melanoma cases
▪ 50% clitoral-preclitoral Vaginal Melanoma Differential Diagnoses
▪ 50% arising from labia minora/majora
o Vaginal melanoma • Vaginal carcinoma
o Isointense on T1WI
▪ Predilection for lower 1/3 and for anterior and o Mass of homogeneous intermediate signal intensity
lateral walls
• Size
•
on T2WI
Vaginal metastases
o Ranges between 0.5 and 4 cm; mean size: 1.5 cm
o Far more common than melanoma and account for >
CT Findings 80% of all vaginal tumors
• NECT o Majority occur through direct contiguous spread
o Isoattenuating mass relative to muscle from malignancies from adjacent organs
• CECT • Vaginal sarcoma
o Infiltrative enhancing tumor that can extend to and o Usually leiomyosarcoma
invade local structures o Heterogeneous mass with areas of high T2 signal
intensity corresponding to cystic necrosis in
MR Findings tumor, and pockets of high T1W signal intensity
• T1WI corresponding to acute hemorrhage
o High signal intensity due to paramagnetic effect of
melanin
▪ Better demonstrated on fat-suppressed images with PATHOLOGY
brighter signal as dynamic range narrows, allowing General Features
for detection of subtle signal differences
o May demonstrate low or intermediate signal • Etiology
o Malignant transformation of melanocytes that arise
intensity in cases with low melanin content within
from neural crest cells within basal layer of epidermis
lesion (amelanotic melanoma)
o Hemorrhage and necrosis can be seen in large masses • Genetics
o Increased risk with personal or family history of
• T2WI
melanoma, particularly 1st-degree relatives
o High T2 signal intensity
• T1WI C+ FS Staging, Grading, & Classification
o Tumor demonstrates homogeneous enhancement • Vulvar melanomas
o No enhancement of necrotic areas o Staged according to AJCC TNM system for skin
melanoma
Nuclear Medicine Findings
• PET • Vaginal melanoma
o No staging system has been demonstrated to be
o FDG-18-avid malignancy
o Useful for lymph node and distant metastasis staging useful predictor of prognosis
o A simplified clinical staging system can be used for
Imaging Recommendations purposes of standardization
• Best imaging tool ▪ Stage I: Clinically localized disease
▪ Stage II: Regional lymph node involvement
o MR for local extent and FDG-18 PET/CT for staging
▪ Stage III: Distant metastases
DIFFERENTIAL DIAGNOSIS Gross Pathologic & Surgical Features

Vulvar Melanoma Differential Diagnoses
• Pigmented vulvar mass with irregular or scalloped
borders, often black; ulceration may be present
• Vulvar squamous carcinoma Microscopic Features
o Most common type of vulvar cancer; slow growing
tumor; distant metastases are rare and mortality is • In situ malignant melanoma composed of atypical
epidermal melanocytes arranged in nests without
low compared to vulvar melanoma
• Atypical melanocytic nevus, genital type
invasion into dermis
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• Tumor cells may be round (epithelioid) or spindle ▪ Lesions on labia minora with involvement of
shaped and may or may not contain melanin pigment urethra and vagina have a worse prognosis due to
(amelanotic melanoma) technical difficulty in achieving clear margins
• Malignant melanoma can show radial (growth is in a ▪ Most important prognostic factor is AJCC TNM
horizontal direction) or vertical growth pattern within stage
dermis o Vaginal melanoma
• Breslow thickness is measurement of tumor taken ▪ 5-year survival rate: 5-25%
from top of granular layer overlying tumor to deepest
Treatment
• Surgical treatment
melanoma cells
• Clark level indicates depth of tumor
o Vulvar melanoma
o Level 1: Tumor confined to epidermis
o Level 2: Tumor in papillary dermis but not filling or ▪ Wide local excision with unilateral sentinel lymph
expanding it node evaluation
o Level 3: Tumor fills and expands papillary dermis ▪ Radical vulvectomy is reserved for large tumors
o Level 4: Tumor present in reticular dermis primarily to obtain local disease control
o Level 5: Tumor in subcutaneous fat ▪ Melanomas < 1 mm thick should be treated with 1
• Immunohistochemical stains are positive for Melan-A, cm skin margins
– Margins can be extended to 2 cm for thicker
S100, HMB-45
melanomas, if feasible
o Vaginal melanoma
CLINICAL ISSUES ▪ Wide local excision if possible
– Achieving negative margins can be difficult
Presentation
without pelvic exenteration, given high
frequency of multifocality and anatomic
o Vaginal melanoma constraints
▪ Vaginal bleeding, discharge
▪ Palpable vaginal mass
• Nodal dissection with adjuvant therapy with interferon
α-2b is reserved for patients with lymph node
o Vulval melanoma metastasis
▪ Mass with irregular border and color variegation
(blue, brown, black, red)
• Adjuvant treatments for advanced stage disease include
chemotherapy, radiation therapy, and immunotherapy
▪ Pruritus (persistent pruritus can be earliest
symptom of disease), bleeding, discharge, burning,
ulceration DIAGNOSTIC CHECKLIST
Demographics Consider
• Age • Diagnosis made by physical examination and biopsy
o Peak incidence in the 6th-7th decade of life, with a • MR is used to estimate local extent of disease in order to
median age at diagnosis of 66 years guide surgery
• Epidemiology Image Interpretation Pearls
o Vulvovaginal melanoma is a rare disease
▪ Vulvar melanoma
• Commonly manifests as a high signal intensity T1WI
vulvovaginal lesion; however, amelanotic melanoma
– 2nd most common vulvar malignancy (5-10% of can be of low or intermediate T1 signal
all primary malignant tumors of vulva)
– Accounts for < 2% of all melanomas
▪ Vaginal melanoma SELECTED REFERENCES
– Incidence of only 0.46 cases per million women 1. Trone JC et al: Melanomas of the female genital tract: state
per year of the art. Bull Cancer. 101(1):102-106, 2014
– Accounts for < 1% of all malignant melanoma 2. Janco JM et al: Vulvar and vaginal melanoma: case series
– Accounts for < 3% of all primary malignant and review of current management options including
tumors of vagina neoadjuvant chemotherapy. Gynecol Oncol. 129(3):533-7,
2013
Natural History & Prognosis 3. Keller DS et al: Outcomes in patients with mucosal
• Prognosis is poor melanomas. J Surg Oncol. 108(8):516-20, 2013
o Vulval melanoma 4. Mert I et al: Vulvar/vaginal melanoma: an updated
surveillance epidemiology and end results database review,
▪ 5-year survival rates of 24-77%
comparison with cutaneous melanoma and significance of
– Stage 0: 77% racial disparities. Int J Gynecol Cancer. 23(6):1118-25, 2013
– Stage I: 70% 5. Hosseinzadeh K et al: Imaging of the female perineum in
– Stage II: 50% adults. Radiographics. 32(4):E129-68, 2012
– Stage III: 48% 6. Tcheung WJ et al: Clinicopathologic study of 85 cases of
– Stage IV: 24% melanoma of the female genitalia. J Am Acad Dermatol.
▪ Local recurrence frequent 67(4):598-605, 2012
▪ Central lesions are associated with worse prognosis 7. Parikh JH et al: MR imaging features of vaginal
malignancies. Radiographics. 28(1):49-63; quiz 322, 2008
than lateral lesions (37% vs. 61% 10-year
survival rate) due to higher risk for groin nodal
4 involvement and local recurrence
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Vagina and Vulva

with "feeling a mass in the
vagina" shows a large right-sided
vaginal mass demonstrating
high signal intensity relative
to the pelvic skeletal muscles.
Note the very large intratumoral
vessels . (Right) Coronal T2WI
T2 hyperintense vaginal mass .
The mass distends the vagina,
which is filled with ultrasound
gel , and is separate from the
uterus .

patient shows a vaginal mass
demonstrating slightly high signal
intensity relative to the pelvic
skeletal muscles and containing
signal void tubular structures
due to increased vascularity.
(Right) Axial T1WI FS MR in the
same patient shows a vaginal
mass demonstrating slightly
high signal intensity relative to
the pelvic skeletal muscles and
containing signal void tubular
structures due to increased
vascularity.

mass . (Right) Sagittal T1WI
shows marked enhancement
of the vaginal mass . Biopsy
revealed malignant melanoma.
No other sites of melanoma were
discovered.
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Key Facts
Terminology • Isointense to hypointense to muscle on T1;
• Rare mesenchymal tumor that most commonly hyperintense relative to muscle on T2, related to loose
myxoid matrix and high water content of tumor
arises in vulvovaginal region, perineum, and pelvis of
women • Relatively homogeneous with "swirled" low-signal
• "Aggressive" emphasizes the often infiltrative nature
•
bands within hyperintense tumor
Avid heterogeneous contrast enhancement
of tumor and its frequent association with local
recurrence Pathology
• Tumor often misdiagnosed before surgery, and its
• Mesenchymal stellate and spindle-shaped neoplastic
anatomical extent is frequently not perceived until
cells embedded in collagenous and hyaluronic acid,
resection
• Metastases are exceedingly rare, and overall, prognosis
containing stroma with loose myxoid background
is good Clinical Issues
Imaging • Labial swelling with Bartholinitis-like clinical picture
• Large soft tissue mass displaying unusual growth • Surgical excision is treatment of choice
pattern of translevator extension with growth around • Due to risk of recurrence, surgical planning is critical
perineal structures (multidisciplinary approach)
• Tendency to displace rather than infiltrate local
structures such as vagina, urethra, bladder, and rectum

centered in vulva shows a
relatively T2-hyperintense
lobular vulvar mass
expanding the left puborectalis
muscle and levator sling .
Surgical resection proved
this to be an aggressive
angiomyxoma. (Right) Coronal
T1WI C+ FS MR shows the
aggressive angiomyxoma
as an elongated enhancing
mass traversing the levator
ani into the vulva and
displacing the rectum to the
right .

of the pelvis shows an avidly
enhancing mass of the right
pelvic sidewall insinuating
into the vagina and right
perineum , and involving
the levator sling. Surgical
resection proved it to be an
aggressive angiomyxoma.
(Right) Axial T1 C+ subtraction
MR in the same patient, lower
down, shows the enhancing
aggressive angiomyxoma with
translevator extension into
the right vulva , and right
aspect of the vaginal fornix .
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Vagina and Vulva

o "Swirled" enhancing bands within tumor
TERMINOLOGY
representing strands of fibrovascular tissue
Abbreviations ▪ This appearance may relate to presence of bands
• Aggressive angiomyxoma (AAM) of fibromuscular stroma that are stretched as they
protrude through pelvic diaphragm
Definitions
• Rare mesenchymal tumor that most commonly arises Ultrasonographic Findings
in vulvovaginal region, perineum, and pelvis • Hypoechoic mass
o Very rarely arises directly from any pelvic or perineal
organ
▪ "Aggressive" emphasizes often infiltrative nature • Highly vascular mass, supplied by branches of internal
iliac artery
of tumor and its frequent association with local
recurrence Imaging Recommendations
– Frequently misdiagnosed with more common • Best imaging tool
entities, such as Bartholin cyst, lipoma, or hernia o MR to determine extent of primary or recurrent
o Tumor often misdiagnosed before surgery, and its tumor
anatomical extent is frequently not perceived until • Protocol advice
resection o Multiplanar MR of pelvis with dynamic contrast
▪ Metastases are exceedingly rare, and overall, enhancement
prognosis is good ▪ Multiple orthogonal planes are crucial to establish
whether tumor traverses levator ani, essential for
IMAGING surgical planning and complete excision
General Features
• Best diagnostic clue DIFFERENTIAL DIAGNOSIS
o Large soft tissue mass displaying unusual growth Bartholinitis
pattern of translevator extension with growth
around perineal structures
• Can be clinically indistinguishable as AAM usually
presents with labial swelling and Bartholinitis-like
• Location clinical features
o Pelvis, perineum, vulva • Thick-walled cystic mass with rim enhancement
▪ Extension to retroperitoneum, gluteal/thigh/ and infiltrative changes in adjacent fat suggestive of
inguinal regions may be seen inflammation
• Size
Hemangiopericytoma
o Large, slow-growing tumor
▪ Can grow to large size, span and cross levator ani • Large expansile lobulated mass with frequent bleeding
• Morphology due to hypervascular nature
• Prominent serpentine intratumoral vessels
o Well-defined, poorly capsulated, gelatinous mass
o Tendency to displace rather than infiltrate local • Speckled calcifications if present are best seen on CT
structures such as vagina, urethra, bladder, and Vulval Carcinoma
rectum
▪ Can infiltrate local structures (very rare)
• Soft tissue mass that invades rather than displaces
adjacent structures
CT Findings • Intermediate to high signal intensity (SI) rather than
• NECT very high SI on T2WI MR
o Well-defined mass with preservation of fat planes • No characteristic "swirling" pattern on CECT or MR
o Soft tissue attenuation less than muscle • Enlarged inguinal lymph nodes may be seen at
o Displaces rather than infiltrate local structures presentation
• CECT Vulval Angiomyofibroblastoma
o Heterogeneous IV contrast with dense enhancement
o Characteristic "swirling" internal architecture
• Tends to be smaller (typically < 5 cm)
• Usually involves superficial parts of vulva, unlike AAM
MR Findings
• T1WI PATHOLOGY
o Isointense to hypointense to muscle
o Relatively homogeneous General Features
• T2WI • Genetics
o Hyperintense relative to muscle, related to the loose o Chromosomal translocation of 12q13-15 band
myxoid matrix and high water content of tumor involving HMG2 gene has been described
o Relatively homogeneous with "swirled" low-signal
•
bands within hyperintense tumor
STIR • Well-defined, lobular, gelatinous/rubbery mass
o Can appear grayish/blue
o High signal intensity (SI) relative to muscle
• T1WI C+ • Deep pelvic planes are usually involved
o Avid heterogeneous contrast enhancement
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• Tumor tends to grow around structures of pelvic floor DIAGNOSTIC CHECKLIST

without penetrating muscularis layer of vagina or
rectum Consider
Microscopic Features • AAM in young female patient with large vulval mass
• Mesenchymal stellate and spindle-shaped neoplastic that straddles pelvic diaphragm
cells embedded in collagenous and hyaluronic acid, Image Interpretation Pearls
containing stroma with loose myxoid background
o Histologic examination reveals hypocellular
• Large, relatively benign-looking mass with myxoid
signal characteristics on MR and typical "swirling"
and highly vascular tumor with myxoid stroma pattern following intravenous contrast medium
containing cytologically bland stellate or spindled
cells
▪ Tumor cells are characteristically positive for SELECTED REFERENCES
estrogen and progesterone receptors, suggesting 1. Amin A et al: Aggressive angiomyxoma of the vulva. J Obstet
hormonal role in development of tumor Gynaecol. 33(3):325-6, 2013
• Ultrastructurally resemble fibroblasts 2. Bakhtiar UJ et al: Aggressive angiomyxoma of vulva. J Coll
• Hemorrhage and cysts are not features 3.

Physicians Surg Pak. 23(7):507-8, 2013
Elkattah R et al: Aggressive angiomyxoma of the vulva: a
• Nuclear atypia and mitosis absent précis for primary care providers. Case Rep Obstet Gynecol.
• Immunohistochemistry positive for vimentin, but not 2013:183725, 2013
desmin or myosin 4. Huang CC et al: Aggressive angiomyxoma: a small palpable
vulvar lesion with a huge mass in the pelvis. J Low Genit
Tract Dis. 17(1):75-8, 2013
CLINICAL ISSUES 5. Ichinokawa Y et al: Case of aggressive angiomyxoma of the
vulva. J Dermatol. 39(11):934-5, 2012
Presentation 6. Dahiya K et al: Aggressive angiomyxoma of vulva and
• Most common signs/symptoms vagina: a series of three cases and review of literature. Arch
o Labial swelling with Bartholinitis-like clinical picture Gynecol Obstet. 283(5):1145-8, 2011
• Other signs/symptoms 7. Lee CW et al: Aggressive angiomyxoma of the vulva treated
by using a gonadotropin-releasing hormone agonist: a case
o Genitourinary and bowel disturbance due to pressure
report. Eur J Gynaecol Oncol. 32(6):686-8, 2011
effects (rare) 8. Obst M et al: [Aggressive angiomyxoma of the vulva
o Painless presenting as a huge pedunculated tumor.] Ginekol Pol.
• Imaging frequently occurs after clinical suspicion that
9.
82(1):68-70, 2011
Gore GA et al: Aggressive angiomyxoma of female vulva.
tumor represents lipoma, Bartholin cyst, or hernia
• Preoperative histological diagnosis can be difficult
10.
Indian J Cancer. 47(3):352-4, 2010
Kato H et al: Magnetic resonance imaging findings of
o Biopsy yield low, often nondiagnostic myxoid tissue
fibroepithelial polyp of the vulva: radiological-pathological
o Usually requires surgical specimen
correlation. Jpn J Radiol. 28(8):609-12, 2010
Demographics 11. Nalini G et al: Fine needle aspiration cytology in a case of
• Age
recurrent aggressive angiomyxoma of vulva. Cytopathology.
21(3):207-8, 2010
o Most commonly 2nd-4th decade 12. Sun NX et al: Aggressive angiomyxoma of the vulva: case
• Gender report and literature review. J Int Med Res. 38(4):1547-52,
o 90% female; 10% males 2010
• Ethnicity 13. Nava Flores EL et al: [Aggressive angiomyxoma of the vulva.
Case report and literature review.] Ginecol Obstet Mex.
o Usually Caucasian
77(10):487-90, 2009
Natural History & Prognosis 14. Sereda D et al: Aggressive angiomyxoma of the vulva: a case
• Slow growing with displacement rather than invasion report and review of the literature. J Low Genit Tract Dis.
13(1):46-50, 2009
of adjacent structures
• No distant metastasis
15. Varras M et al: Aggressive angiomyxoma of the vulva: our
experience of a rare case with review of the literature. Eur J
• High local recurrence rate of 36-72% Gynaecol Oncol. 27(2):188-92, 2006
o Usually due to inadequate surgical resection because 16. Abu JI et al: Aggressive angiomyxoma of the perineum. Int J
of initial clinical misdiagnosis Gynecol Cancer. 15(6):1097-100, 2005
17. Alobaid A et al: Aggressive angiomyxoma of the vulva or
Treatment perineum: report of three patients. J Obstet Gynaecol Can.
• Surgical excision is treatment of choice 18.
27(11):1023-6, 2005
Dragoumis K et al: Aggressive angiomyxoma of the vulva
o Due to risk of recurrence, surgical planning is critical
extending into the pelvis: report of two cases. J Obstet
(multidisciplinary approach) Gynaecol Res. 31(4):310-3, 2005
o Reoperate if inadequate initial clearance due to 19. Gungor T et al: Aggressive angiomyxoma of the vulva and
misdiagnosis vagina. A common problem: misdiagnosis. Eur J Obstet
• Hormonal treatment with a gonadotropin-releasing
20.
Gynecol Reprod Biol. 112(1):114-6, 2004
Jeyadevan NN et al: Imaging features of aggressive
hormone analogue (GnRH) has shown good response
angiomyxoma. Clin Radiol. 58(2):157-62, 2003
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AGGRESSIVE ANGIOMYXOMA
Vagina and Vulva

shows a lobulated relatively T2-
hyperintense pelvic mass
with translevator extension
and large vulvar component of
the mass . Surgical resection
proved to be an aggressive
angiomyxoma (Right) Axial
T2WI FS MR in a patient with
aggressive angiomyxoma shows
a T2-hyperintense left perineal
mass straddling the levator
ani muscle.
(Left) Axial DWI MR in the

same patient with aggressive
angiomyxoma shows marked
diffusion of the left vulvar mass
. (Right) Coronal T1WI C+
FS MR in a patient with pelvic
pain shows a large infiltrating
enhancing pelvic mass
with translevator extension
and involvement of the vulva
. Note the displacement
of the urinary bladder by
this infiltrating mass. Surgical
debulking proved it to be an
aggressive angiomyxoma.
(Left) Sagittal T2WI FS MR in

the same patient with aggressive
angiomyxoma shows the
elongated nature of this T2-
hyperintense tumor and
classic feature of translevator
extension into the vulva .
(Right) Coronal T2WI C+ FS MR
shows a lobulated enhancing
right pelvic side wall mass
, displacing the rectum
and insinuating into the right
perineum . Surgical resection
proved it to be an aggressive
angiomyxoma.
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Vagina and Vulva MERKEL CELL TUMOR
Key Facts
Terminology • Immunohistochemistry is positive for cytokeratins 7
• Rare neuroendocrine carcinoma with aggressive and 20, epithelial membrane antigen, neurofilaments,
neuron-specific enolase, and chromogranin A
behavior arising from Merkel cells in basal layer of
epidermis Clinical Issues
Imaging • Painless sessile vulvar mass, vulvar irritation, and
• Merkel cell tumors commonly arise in sun-exposed discharge
• Elderly Caucasians with fair skin; average age: 69-75
sites including head and neck, extremities, and
buttocks years
• Most commonly originates from labia majora • Surgery: Radical vulvectomy and lymphadenectomy
• MR is method of choice for the evaluation of local • Chemotherapy: For disseminated disease
extent of tumor • Adjuvant radiotherapy is beneficial for pelvic lymph
• FDG PET/CT is performed to evaluate for metastatic nodes and local recurrences
disease • Fatality rate approaches 100%
Pathology
• Local recurrence and metastasis to lymph nodes, lungs,
liver, and bones are common
• Ultraviolet radiation may be main factor responsible
for development of tumors, but viral Merkel cell
polyoma virus has been implicated

well-defined soft tissue mass
centered in the vulva
that has intermediate signal
intensity. Surgical resection
proved to be Merkel cell
tumor. (Right) Sagittal T2WI
Merkel cell tumor shows the
mass in the vulva.

shows the heterogeneously
enhancing vulvar mass
and left external iliac
lymphadenopathy in a
patient with metastatic Merkel
cell tumor of the vulva. (Right)
Axial CECT shows sclerotic
bone metastases in the
sacral promontory and right
iliac bone and left common
iliac adenopathy .
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MERKEL CELL TUMOR
Vagina and Vulva

TERMINOLOGY Microscopic Features
Synonyms
• Small round or cubic oat-like cells with hyperchromatic
nuclei and small amount of cytoplasm
• Trabecular carcinoma, endocrine carcinoma, primary • Clusters of tumor cells form tubules or rosettes with
cutaneous neuroendocrine carcinoma distinct trabecular pattern
o Immunohistochemistry is positive for cytokeratins
Definitions
• Rare neuroendocrine carcinoma with aggressive 7 and 20, epithelial membrane antigen, and
chromogranin A
behavior arising from Merkel cells in basal layer of
epidermis
CLINICAL ISSUES
o Painless sessile vulvar mass, vulvar irritation, and
• Best diagnostic clue discharge
o Relatively homogeneous cutaneous vulvar soft tissue
o Mass can involve or originate from Bartholin gland
mass
• Location
•
and may mimic Bartholin abscess or cyst
Other signs/symptoms
o Merkel cell tumors commonly arise in sun-exposed
o Malaise, fatigue, and other signs of systemic
sites including head and neck, extremities, and
manifestation are seen in cases of advanced disease
buttocks
o Most commonly originates from labia majora in Demographics
vulva • Age
• Size o Elderly; average 69-75 years
o Variable; can range up to 10 cm
• Gender
CT Findings o Caucasians with fair skin
• CECT • Epidemiology
o Enhancing cutaneous masses o Ultraviolet radiation may be main factor responsible
for development of tumors, but viral Merkel cell
MR Findings polyoma virus has been implicated
• T1WI Natural History & Prognosis
o Low signal intensity
• T2WI • Fatality rate approaches 100%
o Slightly hyperintense relative to muscle • Merkel cell carcinoma of vulva pursues more aggressive
• T1WI C+
clinical behavior than Merkel cell tumor at other
locations
o Moderate enhancement
• Local recurrence and metastasis to lymph nodes, lungs,
Imaging Recommendations liver, and bones are common
• Best imaging tool Treatment
o MR is method of choice for evaluation of local extent
• Surgery: Radical vulvectomy and lymphadenectomy
of tumor
o FDG PET/CT is performed to evaluate for metastatic • Chemotherapy: For disseminated disease
disease • Adjuvant radiotherapy is beneficial for pelvic lymph
nodes and local recurrences
SELECTED REFERENCES
Vulvar Carcinoma 1. Jońska-Gmyrek J et al: [Merkel cell carcinoma of the
• Appears as solid mass frequently associated with vulva - case report and the literature review.] Ginekol Pol.
inguinal or pelvic adenopathy 84(5):385-9, 2013
2. Iavazzo C et al: Vulvar merkel carcinoma: a case report. Case
Vulvar Melanoma Rep Med. 2011:546972, 2011
• May demonstrate high signal intensity on T1WI 3. Albores-Saavedra J et al: Merkel cell carcinoma
demographics, morphology, and survival based on 3870
Bartholin Cyst cases: a population based study. J Cutan Pathol. 37(1):20-7,
• Cystic lesion in vulva 2010
4. Sheikh ZA et al: Neuroendocrine tumor of vulva: a case
report and review of literature. J Cancer Res Ther. 6(3):365-6,
PATHOLOGY 2010
5. Mohit M et al: Merkel cell carcinoma of the vulva. Saudi
Gross Pathologic & Surgical Features Med J. 30(5):717-8, 2009
• Gray-white rubbery mass that involves skin and 6. Zucchi S: Merkel cell carcinoma: case report and literature
subcutaneous tissue review, from a remote region of France. Rural Remote
• Areas of hemorrhage, superficial skin ulcerations, and 7.
Health. 9(1):1072, 2009
Khoury-Collado F et al: Merkel cell carcinoma of the
irregular infiltrative margins are typical
Bartholin's gland. Gynecol Oncol. 97(3):928-31, 2005
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Vagina and Vulva GARTNER DUCT CYSTS
Key Facts
• Classically appear as a simple-appearing cyst arising • Müllerian cyst
from anterolateral upper vaginal wall • Nabothian cyst
o Typically positioned above level of pubic symphysis/
perineal membrane
• Urethral diverticulum
• Ultrasound: Simple anechoic vaginal wall cyst Pathology
o May have internal echoes/debris if infected or • Embryologic mesonephric (wolffian) duct remnant
hemorrhagic
o Increased peripheral Doppler flow with Clinical Issues
inflammation/infection • One of the most common benign vaginal cystic lesions
• CT: Low-attenuation, nonenhancing vaginal wall cyst • Majority are asymptomatic, incidental findings
• MR allows for more definitive characterization • Can be complicated by infection or (rarely)
o Hyperintense on T2WI, hypointense on T1WI malignancy
o May have atypical signal characteristics if infected, • Consider imaging of remainder of urogenital system to
hemorrhagic, or containing proteinaceous contents evaluate for associated anomalies
o Thin nonenhancing wall; nodular or mass-like
enhancement may suggest rare malignancy
• Report size, location, and evidence of complication

a classic Gartner duct cyst
arising from the upper anterior
vaginal wall . Note that
the cyst is adjacent to but
distinct from the urethra .
homogeneous low signal
intensity of the cyst without
suspicious nodular or mass-
like enhancing components.
Gartner duct cysts can be
complicated by infection,
hemorrhage, and (rarely)
malignant degeneration.

ultrasound with color
Doppler shows an avascular
hypoechoic cystic lesion
arising from the upper vaginal
wall. The low-level internal
echoes in this Gartner duct
cyst are due to debris from
prior infection or hemorrhage.
enhancement, which reflects
the cystic nature of the lesion.
(Right) Sagittal T2WI FS MR
in the same patient confirms
a Gartner duct cyst arising
from the upper vaginal wall.
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Vagina and Vulva

TERMINOLOGY ▪ Nodular or mass-like enhancement should be
suspicious for malignant transformation
Definitions o May see irregular peripheral enhancement and fat
• Embryologic remnant of caudal end of mesonephric stranding if infected
(wolffian) duct
IMAGING o Anechoic well-circumscribed vaginal wall mass
▪ May be hypoechoic with internal debris with
General Features
hemorrhage, infection, or proteinaceous content
o Separate from cervix and no communication with
o Rounded cystic lesion arising from vaginal wall
urethral lumen
• Location
• Color Doppler
o Typically originates from anterolateral wall of upper o No central flow
2/3 of vagina ▪ Vascularized component is suspicious for
▪ Can be positioned more inferiorly, even at level of underlying malignancy
hymen o May see increased peripheral Doppler flow if infected
▪ May also arise from mesonephric remnants in
broad ligament Imaging Recommendations
o Typically located above level of pubic symphysis • Best imaging tool
• Size o Ultrasound is commonly used to localize and
o Average size is about 2 cm characterize vaginal cysts
▪ Can grow to exceed 10 cm in diameter in some o MR helpful for definitive characterization in
cases complicated or equivocal cases
• Morphology • Protocol advice
o Round or oval o Perform ultrasound with transvaginal probe partially
o Sharply marginated inserted into vagina to visualize vaginal cyst
o Typically solitary ▪ Consider translabial or transperineal techniques
o Usually simple in appearance o T2WI: Axial, coronal, and sagittal small field of view
▪ Can be complicated by infection, hemorrhage, or o T1WI: Axial
malignancy o T1WI post-contrast FS: Axial, sagittal
CT Findings
• NECT DIFFERENTIAL DIAGNOSIS
o Well-defined fluid attenuation round mass within
Müllerian Cyst
vaginal wall
▪ If cyst contents are proteinaceous or hemorrhagic, • Identical in appearance to Gartner duct cyst
may be higher in attenuation • Differentiation between müllerian and Gartner duct
o Difficult to characterize on unenhanced study cysts is not important clinically
• CECT Nabothian Cyst
o Fluid-density lesion arising from vaginal wall • Located within cervix, often multiple
o No central enhancement
▪ Thin wall without significant enhancement
• May be large with proteinaceous contents
▪ Nodular or mass-like enhancing components may Urethral Diverticulum
suggest rare malignant transformation • Usually located in mid urethra (at level of pubic
o May see irregular peripheral enhancement and fat symphysis)
stranding if infected • Visualization of a diverticular neck extending between
urethral and diverticular lumina is diagnostic
MR Findings
• T1WI Bartholin Gland Cyst
o Homogeneously low in signal intensity, similar to • Cystic lesion located along posterior vaginal introitus
simple fluid • Associated with labia majora below level of pubic
▪ May demonstrate high T1WI signal if symphysis
proteinaceous or hemorrhagic Skene Gland Cyst
• T2WI
• Located in superficial perineum at anterior vaginal
o Homogeneously high signal
introitus
▪ May be intermediate or low signal intensity if
proteinaceous or hemorrhagic
• Inferior to pubic symphysis and positioned at external
urethral meatus
o Coronal & sagittal planes are helpful for confirming
origin from vaginal wall Ectopic Ureterocele
o Thin septation not uncommon • Cystic dilation of distal aspect of ectopic ureter
o Clearly separate from urethra & cervix
• T1WI C+
Vaginal Leiomyoma
• Rare, solid mass of vaginal wall
o No central enhancement
▪ May have minimal enhancement of thin wall 4
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Periurethral Collagen Injections o Typically present in 3rd through 5th decades

• Used to treat female stress urinary incontinence o Extremely rare in infants
• Collagen injections can migrate and have variable • Epidemiology
appearances on imaging o One of the most common benign cystic lesions of
vagina
Müllerian Duct Anomaly With ▪ At least 11% of all vaginal cysts
Hematometrocolpos o Up to 1-2% of women
• Uterus &/or vagina distended with blood products Natural History & Prognosis
• May be secondary to vaginal septum • Typically do not enlarge
• Often presents clinically with primary amenorrhea • Usually remain asymptomatic
Imperforate Hymen • Rarely can become infected and form an abscess
• Results in hematocolpos • Malignant degeneration to clear cell adenocarcinoma is
exceedingly rare
o Treated with surgical resection and vaginal
PATHOLOGY reconstruction, external beam radiotherapy, &/or
General Features brachytherapy
• Etiology Treatment
o Embryologic remnants of mesonephric (wolffian) • Most require no treatment
duct
▪ Regresses in females between 8th and 10th weeks
• If symptomatic or large, therapy may be considered
o Marsupialization
of gestation o Resection
• Associated abnormalities o Aspiration with intracystic tetracycline injection
o Abnormalities of metanephric system
▪ Ipsilateral renal dysplasia or agenesis
• Consider imaging of remainder of urogenital system to
evaluate for associated anomalies
▪ Ectopic ureter
▪ Crossed, fused renal ectopia
o Abnormalities of paramesonephric (müllerian) DIAGNOSTIC CHECKLIST
system Consider
▪ Ipsilateral müllerian duct obstruction
▪ Bicornuate uterus • Gartner duct cyst for a simple-appearing lesion arising
from anterolateral upper vaginal wall
▪ Uterus didelphys
▪ Diverticulosis of fallopian tubes Image Interpretation Pearls
Gross Pathologic & Surgical Features • Simple cyst arising from anterolateral vaginal wall
• Cyst located within anterolateral vaginal wall Reporting Tips
• Cyst fluid is typically white, viscous, nonmucinous • Report size, location, and evidence of complication
• Positioned between mucosa and muscularis propria SELECTED REFERENCES
• Lined by nonciliated, nonmucinous cuboidal or low 1. Heller DS: Vaginal cysts: a pathology review. J Low Genit
columnar epithelium Tract Dis. 16(2):140-4, 2012
• Presence of basement membrane and smooth muscle 2. Walker DK et al: Overlooked diseases of the vagina: a
directed anatomic-pathologic approach for imaging
layer can help distinguish from müllerian cysts
• Large pale nuclei, periodic acid-Schiff and cytoplasmic assessment. Radiographics. 31(6):1583-98, 2011
3. Chaudhari VV et al: MR imaging and US of female urethral
mucicarmine negative
• May have foci of squamous metaplasia and periurethral disease. Radiographics. 30(7):1857-74,
2010
4. Bats AS et al: Malignant transformation of Gartner cyst. Int J
Gynecol Cancer. 19(9):1655-7, 2009
CLINICAL ISSUES 5. Griffin N et al: Magnetic resonance imaging of vaginal and
Presentation vulval pathology. Eur Radiol. 18(6):1269-80, 2008
• Most common signs/symptoms 6. Binsaleh S et al: Gartner duct cyst simplified treatment
approach. Int Urol Nephrol. 21, 2006
o Majority are asymptomatic, incidental findings 7. Dwyer PL et al: Congenital urogenital anomalies that are
o Typically solitary; multifocal lesions are uncommon associated with the persistence of Gartner's duct: a review.
• Other signs/symptoms Am J Obstet Gynecol. 195(2):354-9, 2006
o Palpable vaginal wall mass 8. Hahn WY et al: MRI of female urethral and periurethral
o May have urinary tract symptoms if cyst is inferiorly disorders. AJR Am J Roentgenol. 182(3):677-82, 2004
9. Eilber KS et al: Benign cystic lesions of the vagina: a
located and exerts mass effect on urethra literature review. J Urol. 170(3):717-22, 2003
o Pelvic pain 10. Sherer DM et al: Transvaginal ultrasonographic depiction of
o Dyspareunia a Gartner duct cyst. J Ultrasound Med. 20(11):1253-5, 2001
o May interfere with childbirth if large
Demographics
4 • Age
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ultrasound with color Doppler
shows a hypoechoic avascular
mass arising from the vaginal
wall. The posterior acoustic
enhancement confirms
the cystic nature of the lesion.
same patient shows a well-
marginated homogeneously
hyperintense cyst arising
from the anterolateral vaginal
wall. Note the faint hypointense
rim , which represents
hemosiderin deposition from
prior hemorrhage.

patient shows the Gartner duct
cyst to be homogeneously
hyperintense. This also suggests
complication from prior
hemorrhage. (Right) Axial T2WI
MR in a different patient shows
2 small Gartner duct cysts
arising from the lateral vaginal
wall. Most Gartner duct cysts are
solitary; multifocal lesions are
relatively rare.
(Left) Sagittal T2WI FS MR shows

a large Gartner duct cyst
within the anterior vaginal wall.
Note the fluid-fluid level ,
representing layering material
related to prior infection or
hemorrhage. (Right) Axial T2WI
FS MR in the same patient again
demonstrates a Gartner duct cyst
with a subtle fluid-fluid level
. This patient may present
with urinary symptoms owing
to mass effect on the adjacent
urethra .
4
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Vagina and Vulva BARTHOLIN CYSTS
Key Facts
Imaging o Nodular mass-like enhancement suggests rare
• Smoothly marginated round/ovoid vulvar cyst •
malignant transformation
US: Thin-walled anechoic vulvar cyst
o Thin wall without significant adjacent inflammatory
o Best seen on transperineal/translabial ultrasound
change
• Positioned at posterolateral aspect of vaginal introitus • MR is preferred modality secondary to multiplanar
o Located within superficial perineal pouch, below capabilities and excellent soft tissue contrast
perineal membrane/pubic symphysis Top Differential Diagnoses
• Typically solitary but can be multiple, bilateral • Skene gland cyst
• CECT: Low-density nonenhancing mass • Gartner duct cyst
o Wall is uniformly thin, may show minimal
enhancement
• Bartholinitis
o May have thin internal septation Clinical Issues
• T1WI: Commonly hypointense, though appearance • Most patients are asymptomatic
may vary depending on protein/hemorrhagic content • Cyst formation is most common in reproductive years
• T2WI: Homogeneous high signal (2nd and 3rd decades of life)
• Post-contrast T1WI FS: No central enhancement • Secondary infection and abscess formation not
o Thickened enhancing wall may indicate infection uncommon
• Rarely, malignancy can arise from a Bartholin gland

a low-density cystic lesion
along the left posterior aspect
of the vaginal introitus. This
is a classic location and CT
appearance for a Bartholin
cyst, which are common
incidental findings. (Right)
Axial CECT in a different
patient shows bilateral cystic
lesions along the posterior
vaginal introitus . Bartholin
cysts are usually solitary and
unilocular; less commonly,
they can be multiple and
contain thin septations.
(Left) Coronal T1WI MR shows

a small, rounded, hyperintense
cystic lesion along the left
vaginal introitus. T1 signal
of Bartholin cysts can vary
depending on the amount of
proteinaceous or hemorrhagic
content. (Right) Sagittal T1WI
the hyperintense Bartholin cyst
. Note the cyst's position
along the posterior vaginal
introitus, distinguishing it from
the more anterior Skene gland
cyst., which is positioned at
the external urethral meatus.
4
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Vagina and Vulva

TERMINOLOGY • T2WI
o Homogeneous high signal intensity
Synonyms ▪ May be heterogeneous if complicated by infection/
• Greater vestibular gland cyst hemorrhage
• Major vestibular gland cyst o Smoothly marginated, thin wall
o Thin internal septations may be present
Definitions • T1WI C+
• Cystic dilatation of Bartholin glands o No significant wall enhancement
▪ Thin minimally enhancing septations may be
IMAGING present
▪ Wall may be thickened and enhance if infected
General Features (bartholinitis)
• Best diagnostic clue ▪ Enhancing mass-like component may indicate
o Well-defined rounded vulvar cyst positioned at malignant transformation
posterolateral aspect of vaginal introitus Ultrasonographic Findings
• Location
o Normal Bartholin glands are located bilaterally at
o Thin-walled anechoic vulvar cyst
posterior vaginal introitus at base of labia minora
▪ Best seen on transperineal/translabial ultrasound
▪ Normal glands measure about 0.5-1 cm in diameter
▪ Easily overlooked on routine transabdominal or
▪ Glands drain into ducts ~ 1.5-2.5 cm long
endovaginal ultrasound
▪ Bartholin gland ducts empty into vestibule at o Posterior acoustic enhancement
4- and 8-o'clock positions along posterolateral o May appear hypoechoic with internal echoes if
vaginal introitus
complicated by previous infection/hemorrhage
▪ Secrete mucin to provide vulvovaginal moisture/
lubrication • Color Doppler
o No color flow should be seen
o Bartholin cysts are located along posterolateral
▪ Prominent peripheral flow may suggest infection
vaginal introitus in superficial perineal pouch
▪ Flow in a mass-like component may indicate
▪ Positioned below level of pubic symphysis/
perineal membrane
▪ Medial to labia minora Imaging Recommendations
• Size • Best imaging tool
o Usually 1-4 cm in diameter o MR is preferred modality secondary to multiplanar
o May grow to as large as 10 cm capabilities and excellent soft tissue contrast
o Can increase in size with repeated sexual stimulation o Transperineal/translabial US may identify Bartholin
• Morphology gland cysts
o Smoothly marginated round/ovoid cysts
o Thin wall
• Protocol advice
o MR: Ensure FOV includes entire perineum
o No significant adjacent inflammatory change ▪ T1: Axial
o Typically solitary but can be multiple and bilateral ▪ T2: Axial and sagittal
• Embryology ▪ T1 C+: Axial and sagittal
o Bartholin glands arise from urogenital sinus o US: Use translabial or transperineal technique
o Analogous to male Cowper (bulbourethral) glands
CT Findings DIFFERENTIAL DIAGNOSIS

• NECT
Bartholinitis
o Low-density cystic mass at posterolateral vaginal
introitus • Infection of Bartholin gland cyst
• CECT • Bartholin cyst with thickened enhancing wall and
o Low-density mass without significant enhancement adjacent inflammatory changes
▪ Wall is uniformly thin, may show minimal Skene Gland Cyst
enhancement
▪ May have thin internal septation
• Cystic dilation of a Skene gland
▪ Thickened enhancing wall with adjacent
• Positioned anteriorly in vaginal introitus at external
urethral meatus
inflammatory change may indicate infection
(bartholinitis) Gartner Duct Cyst
▪ Enhancing mass-like component may suggest • Simple cyst arising from anterolateral vaginal wall
malignant transformation • Typically above level of pubic symphysis/perineal
membrane
MR Findings
• T1WI Epidermal Inclusion Cyst
o Well-marginated low- to intermediate-signal mass • Subcutaneous lesion most commonly arising from labia
▪ Signal intensity may vary depending on protein/ majora
hemorrhagic content • Mobile, nontender
o Thin imperceptible wall • Often secondary to trauma or surgery 4
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Urethral Diverticulum • Secondary infection and abscess formation not

• Cystic lesion surrounding or at margin of mid urethra uncommon
• May see communication with urethral lumen • Rarely, malignancy can arise from a Bartholin gland
o 40% are adenocarcinomas
• Typically above level of pubic symphysis/perineal o 40% are squamous cell carcinomas
membrane
o New Bartholin cyst after age 40 may raise suspicion
Adenocarcinoma of Bartholin Gland for malignancy
• Significant enhancing soft tissue component
• Can be difficult to differentiate from chronic Treatment
• Small asymptomatic cysts require no treatment
bartholinitis
• If symptomatic, primary therapy is marsupialization
o Preserves gland function
PATHOLOGY o Recurrence rates vary between 0-24%
General Features • Other therapies may include
o Gland/cyst resection (may be indicated for recurrent
• Etiology
cysts)
o Bartholin gland ductal obstruction leads to cystic
o Fistulization
dilation of gland o Aspiration
▪ May be result of vulvovaginal surgery, trauma,
o Ablation with thermal cauterization, silver nitrate,
inspissated secretions, or prior infection
carbon dioxide laser, alcohol
▪ Less commonly, obstruction may be secondary to
stone in gland or duct • Other therapies may be necessary if infected

• Appear clinically as a focal bulging mass in paramidline DIAGNOSTIC CHECKLIST
posterior vulva Image Interpretation Pearls
• Cyst may arise from dilated duct or gland • Vulvar cyst along posterolateral vaginal introitus
Microscopic Features Reporting Tips
• Lining of Bartholin gland/duct varies with location • Describe enhancement suspicious for infection or
o Ducts lined with single layer of cuboidal, malignant degeneration
transitional, or stratified epithelium
o Glands are lined by mucus-secreting columnar
epithelium SELECTED REFERENCES
• Cytoplasm contains secretory granules and 1. Hosseinzadeh K et al: Imaging of the female perineum in
granulofibrillar bodies adults. Radiographics. 32(4):E129-68, 2012
• Glands are arranged in lobules 2. Walker DK et al: Overlooked diseases of the vagina: a
• Lining of cyst wall varies with origin directed anatomic-pathologic approach for imaging
assessment. Radiographics. 31(6):1583-98, 2011
o Ductal origin → transitional or stratified epithelium 3. Chaudhari VV et al: MR imaging and US of female urethral
o Glandular origin → mucinous columnar epithelium and periurethral disease. Radiographics. 30(7):1857-74,
2010
4. Dujardin M et al: Cystic lesions of the female reproductive
CLINICAL ISSUES system: a review. JBR-BTR. 93(2):56-61, 2010
5. Wechter ME et al: Management of Bartholin duct cysts
Presentation
and abscesses: a systematic review. Obstet Gynecol Surv.
64(6):395-404, 2009
o Many patients are asymptomatic 6. Griffin N et al: Magnetic resonance imaging of vaginal and
• Other signs/symptoms vulval pathology. Eur Radiol. 18(6):1269-80, 2008
o Palpable vulvar mass at posterolateral vaginal 7. Elsayes KM et al: Vaginal masses: magnetic resonance
imaging features with pathologic correlation. Acta Radiol.
introitus
48(8):921-33, 2007
o Dyspareunia
8. Rouzier R et al: Unusual presentation of Bartholin's gland
o Pain/signs of infection suggest bartholinitis duct cysts: anterior expansions. BJOG. 112(8):1150-2, 2005
9. Eilber KS et al: Benign cystic lesions of the vagina: a
Demographics
• Age
literature review. J Urol. 170(3):717-22, 2003
10. Omole F et al: Management of Bartholin's duct cyst and
o Cyst formation is most common in reproductive gland abscess. Am Fam Physician. 68(1):135-40, 2003
years (2nd and 3rd decades of life)
▪ Glands begin to function at puberty
▪ Bartholin glands gradually involute after age 30
• Epidemiology
o 2% of women will develop a Bartholin cyst or abscess
in their lifetime
o Most common vulvar cyst

4 • Some cysts may resolve spontaneously
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BARTHOLIN CYSTS
Vagina and Vulva

demonstrates a well-marginated
hyperintense simple cyst
along the posterolateral aspect
of the vaginal introitus, below
the level of the pubic symphysis.
This is a typical location and
appearance for a Bartholin cyst.
same patient demonstrates the
Bartholin cyst . There are
no surrounding inflammatory
changes to suggest infection/
Bartholinitis.

midline posterior Bartholin cyst
. Note the homogeneous
hyperintensity and thin
peripheral hypointense
hemosiderin rim, suggestive
of prior hemorrhage. (Right)
patient shows a Bartholin cyst
along the posterior vaginal
introitus. A hemosiderin rim
is better demonstrated on this
image, confirming complication
by previous hemorrhage.

a large left Bartholin cyst
in this patient with a known
urethral diverticulum . The
Bartholin cyst is positioned in
the superficial perineal pouch,
below the perineal membrane
. A diverticulum is typically
positioned above the level of
the perineal membrane/pubic
symphysis. (Right) Axial CECT
in a different patient shows a
left-sided Bartholin cyst .A
thin enhancing wall may be
present; a thickened wall with fat
stranding suggests infection.
4
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Vagina and Vulva BARTHOLINITIS
Key Facts
Terminology • T2WI: High signal intensity uni- or multilocular cystic
• Infection of dilated/obstructed Bartholin gland, lesion
• T1 C+ FS: Thickened irregular enhancing wall with
leading to abscess formation
• Bartholin cysts/abscesses are located along surrounding inflammation
• US: Introital cyst best seen with transperineal/
posterolateral vaginal introitus in superficial perineal
pouch translabial techniques
o Positioned below level of pubic symphysis and o Increased peripheral Doppler flow indicative of
perineal membrane infection/inflammation
o Can be bilateral, multilocular o May have septation, internal debris

• CECT: Low-density lesion with rim-like enhancement • Bartholin cyst
o Peripheral enhancement may be slightly irregular • Skene gland cyst
o May see thin internal enhancing septations • Gartner duct cyst
o Adjacent inflammatory fat stranding • Bartholin gland carcinoma
• T1WI: Well-marginated lesion of variable signal
Clinical Issues
intensity depending on amount of protein &/or
hemorrhage • Bartholinitis is typically a clinical diagnosis but may be
suggested with signs of inflammation on imaging
(Left) Axial T2WI demonstrates

bilateral heterogeneous cystic
lesions positioned at the
posterior vaginal introitus.
Positioning within the posterior
superficial perineal pouch
suggests Bartholin gland
origin. (Right) Axial T1 C+
demonstrates nonenhancing
cystic components with
somewhat irregular peripheral
enhancement . These
findings are suggestive of
bartholinitis.
(Left) Coronal T1WI C+

demonstrates bilateral
bartholinitis with small
gland cysts and peripheral
enhancement. Note the
air-filled rectum , and
retroflexed fibroid uterus
. (Right) Axial CECT in a
different patient demonstrates
a multilocular cystic lesion
with peripheral enhancement
at the posterolateral vaginal
introitus. This patient
presented with a tender vulvar
mass clinically suspicious for
bartholinitis.
4
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BARTHOLINITIS
Vagina and Vulva

TERMINOLOGY • Increased peripheral Doppler flow indicates infection/
inflammation
Synonyms • May see induration/edema of adjacent tissues
• Greater vestibular gland infection/abscess Imaging Recommendations
• Major vestibular gland infection/abscess • Best imaging tool
Definitions o Bartholinitis is typically a clinical diagnosis
• Infection of 1 or both dilated/obstructed Bartholin ▪ Suggested on imaging if there is peripheral
glands, often leading to abscess formation enhancement, adjacent inflammatory fat
stranding, or increased peripheral Doppler flow
around a Bartholin cyst
IMAGING o MR can be performed to confirm diagnosis if in
General Features doubt and to detect complications (e.g., abscess or
• Location •
mass)
Protocol advice
o Paired Bartholin glands located bilaterally at
o MR: Superior modality owing to multiplanar
posterior vaginal introitus at base of labia minora
▪ Normal glands measure about 0.5-1 cm in diameter capabilities and soft tissue differentiation
▪ Glands drain into ducts ~ 1.5-2.5 cm long ▪ T2WI: Axial, sagittal, and coronal small field of
▪ Bartholin gland ducts empty into vestibule at 4- view (FOV) through perineum
and 8-o'clock positions at level of vaginal introitus ▪ T1WI: Axial small FOV ± fat suppression
o Bartholin cysts develop along posterolateral vaginal ▪ T1WI C+: Axial and coronal small FOV
o US: Consider transperineal or translabial technique
introitus in superficial perineal pouch
▪ Positioned below level of pubic symphysis
o Cysts are typically 1-4 cm in diameter, though can be
larger Bartholin Cyst
▪ Can increase in size with repeated sexual • Sterile dilation of Bartholin gland
stimulation • Thin-walled without significant peripheral
• Morphology enhancement
o Smoothly marginated uni- or multilocular cystic • Usually fluid attenuation/signal, though may have
lesions proteinaceous contents
o Surrounding soft tissue/fat inflammatory changes
Skene Gland Cyst
o Majority are unilateral, but bilateral lesions are not
uncommon
• Cyst positioned within anterior vaginal introitus at
•
external urethral orifice
Embryologically, Bartholin glands arise from urogenital
sinus Gartner Duct Cyst
o Analogous to male Cowper (bulbourethral) glands • Simple cyst arising from anterolateral vaginal wall
CT Findings • Typically above level of pubic symphysis/perineal
• NECT: Low-density mass along posterolateral vaginal membrane
introitus Epidermal Inclusion Cyst
• CECT: Low-density lesion with irregular rim-like • Subcutaneous lesion most commonly arising from labia
enhancement majora
o May see thin internal enhancing septations • Mobile and nontender
o Adjacent inflammatory fat stranding
• Often secondary to trauma or surgery
MR Findings Bartholin Gland Carcinoma
• T1WI: Well-marginated lesion of variable signal • Enhancing soft tissue vulvar mass centered at vaginal
intensity depending on amount of protein &/or introitus
•
hemorrhage
T2WI: High signal intensity uni- or multilocular cystic
• Can be difficult to differentiate from chronic
bartholinitis
lesion in posterolateral vaginal introitus/perineum
o High signal intensity in surrounding tissues indicates • New Bartholin cyst in patient over age of 40 years may
be suspicious for malignancy
inflammatory edema
• T1 C+ FS: Thickened enhancing wall, which may be Vulval Carcinoma
irregular • Older age group
o Nodular or mass-like enhancement may be • Locally aggressive solid vulvar soft tissue mass ±
suspicious for malignant degeneration inguinal lymphadenopathy
• Unilocular, thick-walled cyst along posterolateral PATHOLOGY
vaginal introitus
o Best seen on transperineal/translabial ultrasound General Features
o Easily overlooked on routine transabdominal or • Etiology
endovaginal ultrasound
4
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o Obstruction of distal Bartholin duct → retention • Other techniques include ablation with thermal
of gland secretions → cyst formation → secondary cauterization, silver nitrate, carbon dioxide laser,
infection alcohol
▪ Ductal obstruction may be result of vulvovaginal
surgery, trauma, or prior infection
▪ Less commonly, obstruction may be secondary to
obstructing stone in Bartholin gland or duct Consider
o Infection is typically polymicrobial
▪ Anaerobes, gram-negative bacilli, Neisseria
• Bartholinitis with cystic lesion at posterior vaginal
introitus that demonstrates peripheral rim-like
gonorrhoeae, Chlamydia trachomatis enhancement and surrounding inflammatory changes
o Preexisting cyst not essential
▪ Bartholinitis can arise from nondilated gland
SELECTED REFERENCES
• Bulging distal vaginal wall mass with overlying mucosal 1. Berger MB et al: Incidental bartholin gland cysts identified
on pelvic magnetic resonance imaging. Obstet Gynecol.
inflammation
• May see purulent drainage from ductal orifice
120(4):798-802, 2012
adults. Radiographics. 32(4):E129-68, 2012
3. Walker DK et al: Overlooked diseases of the vagina: a
CLINICAL ISSUES directed anatomic-pathologic approach for imaging
assessment. Radiographics. 31(6):1583-98, 2011
Presentation 4. Bora SA et al: Bartholin's, vulval and perineal abscesses. Best
• Most common signs/symptoms Pract Res Clin Obstet Gynaecol. 23(5):661-6, 2009
o Pain on walking or sitting 5. Wechter ME et al: Management of Bartholin duct cysts
o Dyspareunia and abscesses: a systematic review. Obstet Gynecol Surv.
o Tender mass at introitus 64(6):395-404, 2009
• Other signs/symptoms 6. Griffin N et al: Magnetic resonance imaging of vaginal and
vulval pathology. Eur Radiol. 18(6):1269-80, 2008
o May be asymptomatic 7. Kozawa E et al: MR findings of a giant Bartholin's duct cyst.
Magn Reson Med Sci. 7(2):101-3, 2008
Demographics
• Age
8. Elsayes KM et al: Vaginal masses: magnetic resonance
imaging features with pathologic correlation. Acta Radiol.
o Most common in reproductive years (2nd and 3rd 48(8):921-33, 2007
decades of life) 9. Cunningham, FG et al: Williams Obstetrics. 22nd ed. New
o Bartholin glands gradually involute in patients older York: McGraw-Hill, 2005
than 30 years 10. Rouzier R et al: Unusual presentation of Bartholin's gland
• Epidemiology
11.
duct cysts: anterior expansions. BJOG. 112(8):1150-2, 2005
Marzano DA et al: The bartholin gland cyst: past, present,
o 2% of women will develop Bartholin cyst or abscess
and future. J Low Genit Tract Dis. 8(3):195-204, 2004
in their lifetime 12. Eilber KS et al: Benign cystic lesions of the vagina: a
literature review. J Urol. 170(3):717-22, 2003
• In most patients, adequate treatment is achieved with
13. Omole F et al: Management of Bartholin's duct cyst and
gland abscess. Am Fam Physician. 68(1):135-40, 2003
antibiotics followed by treatment for underlying cyst 14. Eppel W et al: Ultrasound imaging of Bartholin's cysts.
• In diabetic or immunocompromised patients, Gynecol Obstet Invest. 49(3):179-82, 2000
untreated Bartholin gland abscesses can progress to 15. Siegelman ES et al: High-resolution MR imaging of the
necrotizing fasciitis vagina. Radiographics. 17(5):1183-203, 1997
16. Moulopoulos LA et al: Magnetic resonance imaging and
Treatment computed tomography appearance of asymptomatic
• First-line therapy is broad-spectrum antibiotic paravaginal cysts. Clin Imaging. 17(2):126-32, 1993
treatment
• Incision and drainage for Bartholin gland abscess
o Large abscesses with cellulitis may require drainage/
debridement in operating room
• Marsupialization of Bartholin duct cyst as more
definitive therapy
o Recurrence rates after marsupialization vary between
0-24%
• Placement of Word catheter into abscess cavity to
fistulize with vagina
o Balloon-tipped catheter designed for Bartholin
abscess treatment
o Can be used for gland abscess or cysts
o Tip of catheter left within incised cyst/abscess for 3-4
weeks to allow epithelization of surgically created
tract
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a peripherally enhancing cystic
lesion along the posterior left
vaginal introitus. Bartholinitis
is typically a clinical diagnosis,
though imaging findings can be
confirmatory. (Right) Sagittal
demonstrates a peripherally
enhancing infected Bartholin
cyst . Note its positioning
below the pubic symphysis in
the superficial perineal pouch,
differentiating this lesion from
other pelvic cysts.
(Left) Coronal CECT in the

infected Bartholin cyst in the
left superficial perineum .
There is surrounding soft tissue
inflammatory changes with
edema of the left labia .
(Right) Axial CECT in a different
patient shows a low-density right
introital cystic lesion with
faint peripheral enhancement,
consistent with bartholinitis. This
patient presented with a painful
labial mass and was treated
successfully with antibiotics/
marsupialization.
(Left) Sagittal T2WI FS MR shows

a well-marginated hyperintense
unilocular cystic lesion along
the lateral vaginal introitus.
This is the typical location for a
Bartholin gland cyst. This lesion
demonstrates a mildly thickened
wall. (Right) Axial T1WI C+ FS
peripheral enhancement and
mild inflammatory change about
the introital cyst , consistent
with infection and bartholinitis.
Up to 2% of women will
develop a Bartholin cyst or
abscess throughout their lifetime.
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Key Facts
Terminology o May see associated complicating stones
• Uni- or multilocular cystic lesions adjacent to and • Traditionally imaged with fluoroscopic studies, such as
often surrounding urethra VCUG and double-balloon urethrography

• MR (preferred imaging modality) • Bartholin cyst
o Hyperintense periurethral cystic lesion on T2WI • Skene gland cyst
o Hypointense on T1WI • Gartner duct cyst
o Diverticular neck may be visualized but not always • Urethral tumor
o Irregular wall enhancement or mass-like
components may suggest infection or malignancy Pathology
• US (best viewed with endovaginal or endorectal • Majority are acquired lesions arising from infected/
techniques) inflamed periurethral (Skene) glands
o Well-marginated anechoic periurethral cystic lesions
o Peripheral Doppler flow suggests infection
Clinical Issues
• CT
• Many urethral diverticula are asymptomatic and
discovered incidentally
o Hypointense periurethral cystic lesion o Common symptoms include dysuria, postvoid
o May opacify upon postvoid imaging
dribbling, recurrent UTIs, and dyspareunia

large urethral diverticulum
, which has a nearly
circumferential/saddlebag
morphology. Note
complication by multiple
stones , which should be
noted in the imaging report.
(Right) Axial SSFP MR in a
different patient shows an
eccentric teardrop-shaped
urethral diverticulum along
the posterolateral urethra .
Note the thin hyperintense
diverticular neck extending
between the urethral and
diverticular lumina.

a teardrop-shaped high signal
intensity urethral diverticulum
along the posterolateral
aspect of the urethra .
the urethral diverticulum
to be homogeneously low in
signal intensity and without
enhancing components. Care
should be made to evaluate for
evidence of complication such
as infection, stone formation,
or malignancy.
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Vagina and Vulva

o Stones will appear as hypointense filling defects
TERMINOLOGY
• T2WI
Definitions o High signal intensity periurethral cystic lesion with
• Focal outpouching of urethra into periurethral/ low signal intensity outer wall
urethrovaginal space o Stones will appear as hypointense filling defects
o Diverticular neck appears as linear high signal
between urethral and diverticular lumina
IMAGING o Inflamed/infected diverticula may demonstrate fluid-
General Features fluid levels or low signal intensity
• Best diagnostic clue o Postvoid imaging may allow for better diverticular
o Uni- or multilocular cystic lesion adjacent to and distension and characterization
o Endovaginal/endorectal coils may better define
often surrounding urethra
• Location diverticulum and more reliably identify neck
compared to surface coils
o Most commonly occurs in mid to distal urethra
o Typically arises from posterolateral urethra • T1WI C+
o Infected/inflamed diverticula will have peripheral
• Size
enhancement; central component should not
o Usually < 2 cm in size
• Morphology
enhance
▪ Nodular enhancing focus or thickened enhancing
o Periurethral cystic lesion that communicates with
septation should raise suspicion for tumor
urethral lumen
▪ Teardrop-, horseshoe-, or saddlebag-shaped Ultrasonographic Findings
▪ May extend circumferentially around urethra
o May be multiple in up to 1/3 of cases
o Transabdominal evaluation with full bladder may
o Variable communication with urethral lumen reveal periurethral cystic lesion but is usually difficult
▪ May be narrow or wide to characterize
▪ Diverticular neck may be difficult to visualize o Endovaginal or endorectal US can assess size,
Fluoroscopic Findings location, and content of urethral diverticula
▪ Easily overlooked on endovaginal evaluation if
• Voiding cystourethrogram dedicated urethral evaluation not performed
o Can identify number, position, and size of diverticula
▪ Translabial/transperineal US may afford better
▪ Requires patent diverticular neck for opacification
visualization
▪ May be difficult to identify diverticular neck o Appear as well-marginated anechoic periurethral
o Sensitivity of up to 66% for detection of diverticula
o Presence of filling defects in diverticulum may cystic lesions
▪ May show internal debris and septation if infected
represent stone or tumor
▪ Diverticular neck may be seen as hypoechoic line
o Invasive; requires catheterization and radiation
extending between urethral and diverticulum
exposure
• Retrograde urethrogram
lumina
o Stones will appear as shadowing echogenic focus
o Double-balloon retrograde urethrography has
sensitivity of 90-100%
• Color Doppler
o Infected/inflamed diverticula may show peripheral
▪ Requires specialized equipment and technical skill
color signal; there should be no central vascular flow
– Urethral catheter with proximal and distal
▪ Vascularized irregular septations or mass-like
balloon to "isolate" urethra
components may be indicative of malignancy
– Contrast injected under positive pressure
▪ Better visualization of diverticular neck Imaging Recommendations
▪ Largely replaced by MR secondary to invasive • Best imaging tool
nature, patient discomfort, and limited availability o MR is preferred modality in evaluation of urethral
CT Findings diverticulum because of its multiplanar capabilities
• NECT and excellent soft tissue contrast
o MR allows for visualization of diverticular neck, as
o Low-attenuation periurethral lesion
o Associated hyperdense stone may be seen well as size and number of lesions
o MR can depict complications, such as infection and
• CECT
o Low-attenuation nonenhancing periurethral lesion
▪ Enhancing mass suggests associated tumor
o Inflamed diverticula may have a higher density with DIFFERENTIAL DIAGNOSIS
peripheral enhancement and fat stranding
o Postvoid CT may show diverticular opacification Bartholin Cysts
• Positioned along posterolateral vaginal introitus in
MR Findings superficial perineum
• T1WI Gartner Duct Cysts
o Low signal intensity periurethral lesion
o May have high signal if contents are proteinaceous or • Classically within anterolateral vaginal wall above
pelvic diaphragm
hemorrhagic; may be heterogeneous if infected
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Skene Gland Cyst Demographics

• Along anterior vaginal introitus at external urethral • Age
meatus o Usually present in 3rd through 5th decades, though
Urethral Tumors have been reported in younger females
• Solid mass that expands urethral lumen • Gender
o Much more common in women than in men
Endometrioma • Epidemiology
• Demonstrates high signal intensity on T1WI and o Urethral diverticula occur in up to 6% of women
"shading" on T2WI
• No communication with urethral lumen Treatment
• Medical treatment: Infected diverticula are treated with
Cystocele antibiotics prior to surgery
• Urinary bladder descends below pubococcygeal line • Surgery is required for definitive treatment
• Obvious communication with bladder lumen o Surgical techniques include transvaginal/
endourethral diverticulectomy and marsupialization
of diverticular sac into vagina
PATHOLOGY o Diverticulectomy successful in 86-100% of cases
o Recurrence rates are between 1-29%
General Features o Factors associated with recurrence: Large size (>
• Etiology 4 cm), incomplete resection of diverticular neck,
o Majority are acquired lesions arising from infected/
proximal location, horseshoe/saddlebag morphology
inflamed periurethral (Skene) glands o Complications may include urethrovaginal fistula
▪ Common pathogens include Escherichia coli,
formation and stress incontinence
Neisseria gonorrhoeae, and Chlamydia trachomatis
▪ Recurrent infection and obstruction leads to
periurethral abscess formation, with subsequent DIAGNOSTIC CHECKLIST
decompression into urethral lumen
o Congenital urethral diverticula are rare Consider
▪ Thought to develop from cloacogenic rests, • Urethral diverticula are often incidental findings and
Gartner duct cysts, or müllerian duct cysts have nonspecific symptomology
o Other etiologies include urethral injury during Image Interpretation Pearls
childbirth, surgery, or catheterization
• MR is preferred imaging modality as it is superior in
Gross Pathologic & Surgical Features defining lesion and evaluating for complications
• Urethral evagination consisting of mostly fibrous tissue • Urethral diverticula are uni- or multilocular cystic
• Surrounded by periurethral fascia lesions originating from and typically partially
surrounding urethra
Microscopic Features • Peripheral enhancement suggests infection; solid mass
• Epithelial lining is often absent or irregular septation may indicate malignancy
o If present, may be transitional/squamous epithelium
Reporting Tips
• Chronic inflammation within diverticulum results in
• Report size and number of urethral diverticula, as well
marked fibrosis and adherence of diverticular wall to as presence of complications
neighboring structures o Position of diverticular neck if visible

Presentation 1. El-Nashar SA et al: Incidence of female urethral
• Most common signs/symptoms diverticulum: a population-based analysis and literature
o Many urethral diverticula are asymptomatic and review. Int Urogynecol J. 25(1):73-9, 2014
discovered incidentally
adults. Radiographics. 32(4):E129-68, 2012
o Common symptoms include dysuria, postvoid
3. Dwarkasing RS et al: MRI evaluation of urethral diverticula
dribbling, recurrent UTI, and dyspareunia and differential diagnosis in symptomatic women. AJR Am J
▪ May rarely cause hematuria Roentgenol. 197(3):676-82, 2011
o If infected, may present as a painful anterior vaginal 4. Chaudhari VV et al: MR imaging and US of female urethral
mass with expression of pus from urethra and periurethral disease. Radiographics. 30(7):1857-74,
o May present with nonspecific symptoms and 2010
undergo repeated evaluation/treatment before 5. Chou CP et al: Imaging of female urethral diverticulum: an
update. Radiographics. 28(7):1917-30, 2008
diagnosis
•
6. Patel AK et al: Female urethral diverticula. Curr Opin Urol.
Clinical profile 16(4):248-54, 2006
o Recurrent urinary tract infections occur in ~ 30-50% 7. Prasad SR et al: Cross-sectional imaging of the female
of patients urethra: technique and results. Radiographics. 25(3):749-61,
o May be complicated by stone formation or, rarely, 2005
malignant transformation 8. Kawashima A et al: Imaging of urethral disease: a pictorial
▪ Malignancy is usually diagnosed at late stage and review. Radiographics. 24 Suppl 1:S195-216, 2004
4 treated aggressively
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Vagina and Vulva

demonstrates a multilocular
periurethral cystic lesion
in a patient who previously
underwent diverticulectomy,
consistent with recurrent
diverticulum. Urethra is also
shown . Diverticula recur
in up to 29% of cases. (Right)
Axial NECT shows a crescentic
hypoattenuating cystic lesion
along the lateral mid urethra .
Note the small stone , which
can complicate diverticula in up
to 10% of cases.
(Left) Frontal image from a

double balloon urethrogram
shows opacification of a
diverticular neck along
the lateral aspect of the distal
urethra. Note balloons within
the bladder and distal
urethra , serving to "isolate"
the urethra. (Courtesy Dr. R.
Jesinger.) (Right) Frontal postvoid
image in the same patient shows
a large periurethral contrast
collection , consistent with
a urethral diverticulum. Note
residual contrast in the bladder
. (Courtesy Dr. R. Jesinger.)
(Left) Axial T2WI shows a large,

rounded, periurethral cystic
lesion along the lateral
margin of the urethra . The
diverticulum is heterogeneously
hyperintense, which can be
seen in the setting of infection/
inflammation, though post-
contrast imaging is necessary to
exclude underlying malignancy.
heterogeneous nodular
enhancement within the
diverticulum, suspicious for
malignant degeneration.
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Key Facts
Terminology • US shows cystic lesion positioned at external urethral
• Cystic dilation of Skene (paraurethral) glands meatus
o Best evaluated with translabial/transperineal
secondary to ductal obstruction/stricturing
technique
Imaging
• Rounded or ovoid cystic lesion positioned along Top Differential Diagnoses
• Bartholin gland cyst
lateral/posterior margin of external urethral meatus
within anterior vaginal introitus • Urethral diverticulum
• Located within superficial perineal pouch, inferior to • Gartner duct cyst
perineal membrane and pubic symphysis
• MR imaging is superior modality secondary to superb Diagnostic Checklist
soft tissue differentiation and high resolution • Important to report size and position of lesion as
o Uncomplicated lesions are homogeneously related to external urethral orifice
hypointense on T1WI and hyperintense on T2WI • Evaluate for peripheral enhancement and adjacent
o Cysts complicated by infection or hemorrhage have inflammatory change suggestive of infection
varied signal intensities • Mass-like or nodular enhancement suspicious for
• CT demonstrates low-density cystic lesion within malignant degeneration should be described
anterior perineum
o May be hyperdense if hemorrhagic

pregnant patient demonstrates
a Skene gland cyst
positioned at the external
urethral meatus . (Right)
Coronal SSFP MR in the same
patient shows a Skene gland
cyst in the superficial
perineum along the distal
urethra . Note the gravid
uterus .

demonstrates a well-
marginated hypointense lesion
at the external urethral
meatus. Note positioning
below the level of the pubic
symphysis . (Right) Axial
T1WI FS MR in the same
patient shows the lesion
to be homogeneously
hyperintense. Positioning and
signal characteristics of the
lesion are most suggestive of a
hemorrhagic Skene gland cyst.
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Vagina and Vulva

TERMINOLOGY ▪ Nodular mural enhancement may suggest early
malignancy
Synonyms o Enhancing mass at external urethral meatus may
• Distal paraurethral gland cyst represent a rare Skene gland-related adenocarcinoma
Definitions Ultrasonographic Findings

• Cystic dilation of Skene glands secondary to ductal • Grayscale ultrasound
obstruction/stricturing o Anechoic well-marginated cyst at external urethral
meatus
o May have internal debris if infected
IMAGING o Easily overlooked on routine pelvic imaging with
General Features transabdominal/endovaginal techniques
o Translabial/transperineal imaging is necessary for
• Best diagnostic clue evaluation
o Rounded or ovoid cystic lesion positioned anteriorly
at vaginal introitus adjacent to external urethral • Color Doppler
o No central color flow
meatus
o May have peripheral color flow if infected/inflamed
• Location
o Mass at external urethral meatus with internal color
o Anterior vaginal introitus
o Along lateral or posterior margin of external urethral flow may represent rare malignant degeneration
meatus Imaging Recommendations
o Located within superficial perineal pouch, inferior to
perineal membrane and pubic symphysis o MR imaging is superior modality due to superb soft
o Separate from vaginal wall
tissue differentiation and high resolution
• Size o MR can confirm location and distinguish Skene
o Typically small, < 2 cm gland cysts from other cystic lesions
• Morphology • Protocol advice
o Round, oval, or teardrop-shaped o T2WI: Axial, sagittal, and coronal
o Well marginated o T1WI: Axial
o Typically unilocular o Post-contrast T1WI FS: Axial and sagittal
CT Findings
• NECT DIFFERENTIAL DIAGNOSIS
o Low-attenuation rounded lesion at anterior vaginal
introitus in superficial perineum Bartholin Gland Cyst
o Inferior to perineal membrane within superficial • Positioned along posterolateral vaginal introitus in
perineal pouch superficial perineum
o May be higher in density if hemorrhagic or infected Urethral Diverticulum
• CECT
• Cystic lesion positioned along mid urethra
o Should have thin wall without central enhancement
o May have irregular wall enhancement and adjacent • May demonstrate communication with urethral lumen
fat stranding if infected/inflamed Epidermal Inclusion Cyst
o Mass-like enhancing components may represent rare • Subcutaneous lesion commonly along labia majora
malignant degeneration
Urethral Caruncle
MR Findings • Small solid benign mass along posterior urethra
• T1WI secondary to urethral prolapse
o Uncomplicated cysts have homogeneous low signal
o May have increased signal if cyst contains Gartner Duct Cyst
proteinaceous material or hemorrhage • Classically within anterolateral vaginal wall above
o May be heterogeneous if acutely infected pelvic diaphragm
• T2WI Vulvar Carcinoma
o Uncomplicated lesions have homogeneous high • Enhancing infiltrative solid vulvar mass
signal
o May have decreased signal intensity if complicated by
• Cystic components uncommon
hemorrhage
o If infected PATHOLOGY
▪ May have heterogeneous signal intensity
▪ Surrounding high signal edema/inflammation
General Features
• T1WI C+ FS • Skene glands are paraurethral glands that are
positioned along distal urethra
o Thin wall is typically nonenhancing if
o Positioned at 3-o'clock and 9-o'clock positions
uncomplicated o Typically 2 glands but can be up to 4 in number
o May show peripheral enhancement and wall
o Ducts drain into distal urethral lumen
thickening if infected o Provide for urethral lubrication
o Female analog to prostate gland 4
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• Embryologically originate from urogenital sinus Treatment

Gross Pathologic & Surgical Features • If small and asymptomatic, may not require treatment
• Variably sized submucosal mass along external urethral • Antibiotic therapy if infected
meatus • Larger, symptomatic lesions require surgical excision/
marsupialization
Microscopic Features • Resection contraindicated in setting of acute infection;
• Glands lined by pseudostratified columnar epithelium requires incision and drainage
• Ducts lined by stratified squamous or transitional
epithelium
• Calculi may be present in rare cases DIAGNOSTIC CHECKLIST
Etiology Consider
• Majority are acquired lesions • Skene gland cyst for a simple-appearing anterior vulvar
o Glandular dilation secondary to stenosis or cyst
obstruction of duct • Not uncommon incidental finding on routine cross-
o Often secondary to inflammation &/or infection sectional imaging
(Neisseria gonorrhoeae is most commonly associated Image Interpretation Pearls
pathogen)
o May be related to prior trauma or urethral
• Well-marginated superficial cystic lesion at anterior
vaginal introitus along external urethral meatus
catheterization o Superficial to perineal membrane
• Rarely, may be present at birth • Typically of homogeneous fluid attenuation/signal
o Usually do not require therapy/intervention o Best evaluated on MR imaging
o Majority resolve/drain spontaneously within several
Reporting Tips
• Important to report size and position of lesion as
weeks of birth
related to external urethral orifice
CLINICAL ISSUES • Evaluate for evidence of infection
Presentation • Suspicious mass-like or nodular enhancement
• Most common signs/symptoms suggestive of malignant degeneration should be
described
o Often asymptomatic
o May manifest as dysuria or dyspareunia
o Cystic mass positioned at anterior aspect of vaginal SELECTED REFERENCES
introitus 1. Hosseinzadeh K et al: Imaging of the female perineum in
▪ Characteristically, positioned adjacent to external adults. Radiographics. 32(4):E129-68, 2012
urethral meatus 2. Walker DK et al: Overlooked diseases of the vagina: a
o When large, may cause urethral obstruction and directed anatomic-pathologic approach for imaging
difficulty voiding assessment. Radiographics. 31(6):1583-98, 2011
o May become infected (skenitis) 3. Busto Martín L et al: Cyst of the skene's gland: report of four
▪ Present with pain and overlying mucosal cases and bibliographic review. Arch Esp Urol. 63(3):238-42,
2010
erythema/edema
•
4. Chaudhari VV et al: MR imaging and US of female urethral
Other signs/symptoms and periurethral disease. Radiographics. 30(7):1857-74,
o Enhancing distal periurethral mass may suggest rare 2010
malignancy 5. Chong Y et al: Adenofibroma of skene's duct: a case report.
▪ Skene gland-associated tumors may cause elevated Patholog Res Int. 2010:318973, 2010
levels of prostate-specific antigen (PSA) 6. Fletcher SG et al: Differential diagnosis of chronic pelvic
▪ Typically adenocarcinomas pain in women: the urologist's approach. Nat Rev Urol.
6(10):557-62, 2009
Demographics 7. Prasad SR et al: Cross-sectional imaging of the female
• Age urethra: technique and results. Radiographics. 25(3):749-61,
2005
o Usually present in women of childbearing age
8. Pongtippan A et al: Skene's gland adenocarcinoma
▪ Most commonly in 3rd and 4th decades resembling prostatic adenocarcinoma. Int J Gynecol Pathol.
o Very rarely present in neonates as congenital lesions 23(1):71-4, 2004
• Epidemiology 9. Eilber KS et al: Benign cystic lesions of the vagina: a
o Precise incidence in adult women is not well literature review. J Urol. 170(3):717-22, 2003
established 10. Ceylan H et al: Paraurethral cyst: is conservative
o Congenital lesions seen in up to 1:2,000 to 1:7,000 of management always appropriate? Eur J Pediatr Surg.
12(3):212-4, 2002
live female births 11. Dodson MK et al: Skene's gland adenocarcinoma with
Natural History & Prognosis increased serum level of prostate-specific antigen. Gynecol
• Often asymptomatic Oncol. 55(2):304-7, 1994
• Most common complication is infection

12. Lee NH et al: Skene's duct cysts in female newborns. J Pediatr
Surg. 27(1):15-7, 1992
• Rarely, may undergo malignant degeneration to
adenocarcinoma
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Vagina and Vulva

(Left) Axial T2 MR shows a
hypointense lesion at the
external urethral orifice at the
anterior aspect of the vaginal
introitus. (Right) Axial T1WI
demonstrates the lesion to
be hyperintense. Location of the
lesion and imaging characteristics
are most suggestive of a
hemorrhagic Skene gland cyst.

a classic appearance of a
Skene gland cyst . These are
secondary to ductal obstruction
and subsequent Skene
(paraurethral) gland dilation.
(Right) Sagittal T2WI MR in a
different patient demonstrates a
small hyperintense cystic lesion
positioned at the external
urethral meatus, consistent with
a Skene gland cyst.

a simple-appearing Skene gland
cyst positioned at the anterior
vaginal introitus. (Right) Sagittal
patient shows the Skene gland
hypointense and without
evidence of enhancement.
Nodular enhancing components
or a solid mass at the external
urethral meatus should raise
the suspicion of malignant
degeneration.
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Vagina and Vulva VAGINAL FOREIGN BODIES
Key Facts
Terminology o First-line of investigation when presenting with
• Device or foreign material found within vaginal lumen vaginal bleeding and known foreign body
o Scout CT image displays foreign body
Imaging o Some foreign bodies may not be appreciated on axial
• Plain abdominal radiograph initially; provides images; MPR useful
o If radiopaque marker/strip present it appears as high-
diagnosis in most cases
o Oblique/lateral views may be of use attenuation ring
• Radiopaque objects • Ultrasound can also be performed as first-line of
o Rocks, gravel, mineral fragments investigation when presenting with vaginal bleeding
o Glass, metal • Detailed clinical history very relevant
• Radiolucent objects • Be aware of possible abuse, especially in mentally
o Most food, medicines, fish bones handicapped and children
o Vaginal contraceptive rings and pessaries (without
Clinical Issues
•
marker)
• Vaginal bleeding, discharge, pain
• Removal under general anesthetic and examination
CT/MR useful in
o Foreign bodies located deep in vagina
o Evaluating complications (abscess/migration/organ under anesthesia may be necessary
perforation) • Treat complications (abscess drainage/perforated organ
repair)
(Left) Axial CT maximum

intensity projection shows a
Gellhorn pessary within
the vaginal cavity placed in
prior history of severe uterine
prolapse. (Right) Coronal CT
maximum intensity projection
in the same patient with
Gellhorn pessary shows the T-
shaped disc-like configuration
of the pessary placed in the
vaginal cavity.
(Left) Axial CT maximum

intensity projection shows
a ring-shaped pessary (with
support) placed in a
presented with cystocele
and laxity of the pelvic floor.
patient with ring pessary with
support shows the device
to be situated within the
vaginal cavity. Note that the
center of the ring presents as
a linear dense structure ,
corresponding to the central
support.
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TERMINOLOGY ▪ CHIPES: Chloral hydrate, iodides, phenothiazides,
enteric coated pills, solvents
Definitions • Radiolucent objects
• Device or foreign material found within vaginal lumen o Most food, medicines, fish bones
o Iatrogenic o Splinters, thorns, and most wood
▪ Vaginal pessary o Most plastics, aluminium
▪ Fiducial markers of radiation, intracavitary o Vaginal contraceptive rings and pessaries (without
brachytherapy marker)
▪ Retained surgical swab/sponge ▪ Lucent ring
– Vaginal contraception device o Tampon
o Noniatrogenic • Retained swabs
▪ Traumatic/penetrating injury o Characteristic whirl-like appearance due to gas
▪ Intentional (e.g., tampon, contraceptive ring) trapped within swab fibers
▪ Abuse o Sponge body may be faintly visible
o Sponge marker radiopaque and readily identifiable
IMAGING CT Findings
General Features • Scout image displays foreign body
o Some foreign bodies may not be appreciated on axial
• Size images; MPR is useful
o Inflammatory reaction may form a mass/granuloma
and increase in size with time
• Wooden foreign bodies are linear, cylindric structures
•
of increased attenuation
Morphology
o Metallic, wooden, plastic material
• Metallic foreign bodies may have associated streak
artifact at CT
o Vaginal tampon: Radiolucent elongated object
▪ Sufficient gas normally trapped into fibers
• Plastic foreign bodies are sharp and lucent
o Ring pessary: Characteristic lucent ring
o Vaginal contraceptive ring
▪ If radiopaque marker/strip, appears as high-
▪ In women of reproductive age
attenuation ring
▪ Inserted between days 1-5 of menstrual cycle
▪ In situ for 3 weeks, hormonal release via vaginal
• Retained swabs: Variable appearance
o Complex low- or high-density mass with peripheral
mucosal absorption
enhancement on CECT
▪ Ring removed for 1 week, then new ring inserted o May contain gas pockets centrally (equivalent to
▪ Transparent flexible polymer ring: Radiolucent
whirl-like appearance of plain film)
▪ Low concentration of etonogestrel and estradiol
▪ May lie in any orientation • Vaginal tampon
o Vaginal pessary o Low attenuation distending the vagina
o Can be utilized in CT as negative contrast to provide
▪ In women with pelvic floor laxity, to support pelvic
floor anatomical landmark location
▪ Prevents uterine/vaginal/bladder neck prolapse ▪ Cervix just above termination of low attenuation
▪ Larger in diameter and width than contraceptive region
ring MR Findings
▪ May contain radiodense marker or strip
▪ Positioned in most posterior aspect of vagina
• Wooden foreign bodies
o Variable in signal intensity (SI), equal to or less than
o Retained surgical swab (a.k.a. gossypiboma/
that of skeletal muscle on both T1- and T2-weighted
textiloma) images
▪ Aseptic fibrous tissue reaction; can result in o Surrounding inflammatory response can be
adhesion, encapsulation, and granuloma appreciated as enhancing region
▪ Exudative-type tissue reaction can result in abscess
formation
• Metallic foreign bodies (fiducial markers) demonstrate
strong susceptibility artifact
▪ May organize and increase in size with time
▪ Patient may remain asymptomatic
• Plastic foreign bodies are sharply outlined low-signal
structures
o Brachytherapy implants, a combination of
▪ Tandem: Metal tube placed in uterus
• Tampon shows signal void due to air pockets within
fibers
▪ Ovoids: Metal hollow holders placed in vagina, on
both sides of cervix
• Retained swabs
o Hypointense on T1W images, hyperintense on T2W
▪ Cylinders: Metal hollow holders placed in vagina
images
Radiographic Findings o Characteristic wavy, striped, or spotty appearance of
• Supine film initially gauze fibers
• Oblique/lateral views may be of use Ultrasonographic Findings
• Radiopaque objects • Wooden/metallic foreign bodies are highly echogenic
o Some foods, animal bones, some fish bones and demonstrate acoustic shadowing
o
o
Rocks, gravel, mineral fragments • Pessaries demonstrate characteristic ring-like echogenic
Glass, metal lines
o Some pills and poisons 4
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• Tampon may appear as solid mass but can have ▪ In cases of physical/sexual abuse
echogenic foci, depending on amount of gas trapped o Adults at risk
• Retained swabs ▪ Recent vaginal instrumentation/surgery
o Highly echogenic sharply delineated acoustic ▪ Emotionally disturbed; unusual sexual activities
shadow Natural History & Prognosis
o Less commonly, cystic mass or hypoechoic mass with
• Most foreign bodies do not cause significant injury
• May be encrusted in mineral salts, with inflammatory
irregular internal echoes
Imaging Recommendations reaction and granuloma formation
• Best imaging tool • Mucosal injuries are usually minor
o Plain abdominal radiograph or CT scout o Rarely, may cause severe vaginal bleed
• Protocol advice ▪ Perforation through vaginal wall; migration into
o Plain abdominal radiograph initially peritoneal cavity
▪ Provides diagnosis in most cases ▪ Abscess, fistula formation
o CT/MR useful in
Treatment
▪ Foreign bodies located deep in vagina
▪ Evaluating complications (abscess/migration/ • Removal under general anesthetic and examination
under anesthesia may be necessary
o US
organ perforation)
• Treat complications (abscess drainage/perforated organ
repair)
▪ First-line of investigation when presenting with
vaginal bleeding
o Detailed clinical history very relevant SELECTED REFERENCES
o Be aware of possible abuse, especially in mentally
1. Kyrgios I et al: An unexpected cause of vaginal bleeding: the
handicapped and children role of pelvic radiography. BMJ Case Rep. 2014
2. Boortz HE et al: Migration of intrauterine devices: radiologic
findings and implications for patient care. Radiographics.
DIFFERENTIAL DIAGNOSIS 32(2):335-52, 2012
3. Reiner JS et al: Multimodality imaging of intrauterine
Air in Vagina
• Highly echogenic with associated posterior acoustic
devices with an emphasis on the emerging role of 3-
dimensional ultrasound. Ultrasound Q. 28(4):251-60, 2012
shadowing 4. Russo JK et al: Comparison of 2D and 3D imaging and
treatment planning for postoperative vaginal apex high-
Vaginal Clot
• Characteristic SI on MR, indicating blood products
dose rate brachytherapy for endometrial cancer. Int J Radiat
Oncol Biol Phys. 83(1):e75-80, 2012
5. Burger IA et al: FDG uptake in vaginal tampons is caused by
Vaginal Carcinoma
• Locally invasive soft tissue mass; enlarged inguinal &/
urinary contamination and related to tampon position. Eur
J Nucl Med Mol Imaging. 38(1):90-6, 2011
or retroperitoneal lymph nodes may be present 6. Mausner EV et al: Commonly encountered foreign bodies
and devices in the female pelvis: MDCT appearances. AJR
Vaginitis Emphysematosa
• Located within vaginal wall rather than within lumen
Am J Roentgenol. 196(4):W461-70, 2011
7. Komesu YM et al: Restoration of continence by pessaries:
• May create low-attenuation ring around vagina magnetic resonance imaging assessment of mechanism of
action. Am J Obstet Gynecol. 198(5):563, 2008
Vaginal Fistula 8. Peri N et al: Imaging of intrauterine contraceptive devices. J
• Relevant clinical history is helpful; flecks of air may be 9.
Ultrasound Med. 26(10):1389-401, 2007
Siddiqui NY et al: Vesicovaginal fistula due to an unreported
present within vagina
• MR may demonstrate fistulous track foreign body in an adolescent. J Pediatr Adolesc Gynecol.
20(4):253-5, 2007
10. Striegel AM et al: Vaginal discharge and bleeding in girls
PATHOLOGY younger than 6 years. J Urol. 176(6 Pt 1):2632-5, 2006
11. Lopez C et al: MRI of vaginal conditions. Clin Radiol.
Microscopic Features 60(6):648-62, 2005
• Epithelium may show reactive changes, hyperplastic 12. Hunter TB et al: Foreign bodies. Radiographics.
23(3):731-57, 2003
features, ulceration or necrosis
• Underlying stroma may show chronic inflammation 13. Hunter TB: Special report: medical devices and foreign
bodies: an introduction. Radiographics. 23(1):193-4, 2003
with foreign body giant cells ± granulomata 14. Jawaid M: Gossypiboma: The forgotten swab. Special
Communication. Pak J Med Sci. 19(2):141-3, 2003
15. Simon DA et al: Recurrent, purulent vaginal discharge
CLINICAL ISSUES associated with longstanding presence of a foreign body
Presentation and vaginal stenosis. J Pediatr Adolesc Gynecol. 16(6):361-3,
• Most common signs/symptoms 2003
o Vaginal bleeding, discharge, pain
Demographics
• Age
o Children
4 ▪ Especially if personality/emotional problems
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(Left) Coronal 3D reconstruction
volume-rendered image in a 70-
year-old woman undergoing
adjuvant radiation therapy for
cervical carcinoma shows 2
radiopaque fiducial markers
overlying the expected vaginal
cavity. (Right) Sagittal CT in
the same patient with fiducial
markers placed in the cervix
shows the radiopaque markers
with resultant streak artifact
due to the metallic nature of
these markers.
(Left) Sagittal CT reconstruction

image in a 54-year-old female
shows an inflatable pessary
within the vaginal cavity
of a 54-year-old woman with
moderate uterine prolapse. Note
the air content within the vaginal
component of the inflatable
pessary . (Right) Axial CECT
in the same patient with an
inflatable pessary within
the vagina placed for moderate
uterine prolapse and pelvic floor
relaxation shows the pessary
en face with an air-filled central
cavity.
(Left) Axial CECT reconstructed

image shows the outline of a
lucent ring in the vaginal
cavity, corresponding to the
flexible polymerin hormone-
containing contraceptive device
used in younger women. (Right)
Coronal CT reconstruction image
shows the lucent, hormone-
containing contraceptive ring
device en face , adequately
placed within the vaginal
fornices.
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old woman presenting with
pelvic pain shows distension
of the endometrial cavity with
fluid and mottled foci of
gas and air-fluid level ,
consistent with pyometra in
a patient with an infected
retained pessary. (Right) Axial
CECT lower in the pelvis of
retained Gellhorn pessary
within the vaginal cavity.
(Left) Sagittal CECT

reconstructed image in the
Gellhorn-type pessary in the
vagina and the large air
and fluid collection in the
uterine cavity, consistent with
complicating pyometra. (Right)
3D volume-rendered image
shows a Gellhorn-type pessary
used in patients with severe
pelvic floor laxity and uterine
prolapse.
(Left) Sagittal CT MIP image in

a 48-year-old woman referred
for high-dose radiation and
intracavitary brachytherapy
shows the metallic nature of
the tandem placed within
the vagina with adequate
positioning within the uterus.
There is marked streak artifact
due to the metallic nature of
the tandem. (Right) Sagittal
CT MIP image in the same
patient with intracavitary
brachytherapy shows the
metallic tandem placed
within the vagina, with
adequate positioning within
the uterus.
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(Left) Sagittal CT reconstruction
image shows a radiopaque cup-
shaped device within the vaginal
cavity , corresponding to a
menstrual cup. Menstrual cups
are used to collect menstrual
fluid rather than absorbing
it, as pads and tampons do.
Menstrual cups are considered
an environmentally friendly
alternative. (Right) Coronal 3D
volume-rendered image of a 34-
year-old woman with a menstrual
vaginal cup used as an
alternative means for menstrual
collection shows the cone shape
of the cup.
(Left) Axial CECT reconstructed

image shows an incontinence
ring pessary, with a characteristic
ring and anterior knob
impressing on the urethra.
Rings with knobs are preferred
in women with associated
symptoms of stress urinary
incontinence. The knob exerts
pressure over the bladder neck,
modifying the angle with the
proximal urethra. (Right) 3D
volume-rendered image of an
incontinence ring pessary shows
the typical ring-like configuration
of the pessary with the knob
anteriorly.
(Left) 3D volume-rendered CT
image of a patient undergoing
intracavitary brachytherapy
shows the 2 lateral metallic
ovoids placed in the vaginal
fornices, and central larger
tandem placed in the uterus.
(Right) AP radiograph
in a patient undergoing
intracavitary high-dose radiation/
brachytherapy shows the large
midline tandem in the expected
location of the uterus, and the
2 ovoids placed in the expected
location of the lateral vaginal
fornices.
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(Left) Transverse
of the pelvis demonstrates a
vagina that is full of echogenic
material with a marked
. This was later shown to
be "gravel/rocks" filling the
vagina in a 6-year-old girl.
of the pelvis in the same 6-
year-old child with a "rock"
in her vagina shows the
vagina full of echogenic gravel.
(Left) AP CT scout image of

a CT in a 19-year-old woman
shows an oblong lucent
structure in the midline ,
in the expected location of
the vagina, corresponding to
a tampon. (Right) Coronal
CECT in a 19-year-old woman
shows an oblong lucent
structure in the midline , in
the expected location of the
vagina, corresponding to a
tampon. Note the tampon to
be air filled due to air trapped
in its fibers.

patient shows the air-filled
tampon in the vaginal
cavity. Tampons are a common
incidental finding and should
be recognized as such and
not confused with pathology.
(Right) AP radiograph in a
22-year-old woman with an
underlying psychiatric disorder
shows several curvilinear
radiopaque structures in
the expected location of the
vagina. These proved to be
several ponytail holders on
removal.
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Vagina and Vulva

(Left) AP radiograph in a 24-year-
old mentally challenged woman
shows a rectangular radiopaque
structure with an adjacent
linear radiopaque marker
within a longer lucent structure
in the lower pelvis, in the
expected location of the vagina.
Removal of these foreign bodies
from the vagina proved them
to be dice and a pen. (Right)
AP scout view from a CT in a
linear lucent structure with a
radiopaque cap resembling a
lighter, which was confirmed on
removal.
(Left) Coronal CT image in a 26-

year-old woman presenting with
"falling on a lighter" shows the
lighter high up in the vaginal
cavity. (Right) Axial CT image in
the same patient presenting with
the lost lighter shows the lighter
to be situated in the vagina.

of the pelvis in a 26-year-old
a "stuck" tampon after the
string was broken off shows a
curvilinear echogenic structure
in the vaginal cavity with
corresponding to the lost
tampon. This was subsequently
manually extracted. (Right)
Longitudinal ultrasound image
of the pelvis in the same patient
shows the curvilinear echogenic
tampon in the vaginal
cavity with posterior acoustic
shadowing .
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Vagina and Vulva VAGINAL FISTULA
Key Facts
Terminology • MR: Superior modality owing to multiplanar
• Epithelially-lined abnormal communication between capabilities and soft tissue contrast
o Abnormal T2/STIR linear hyperintensity extending
vaginal lumen and adjacent pelvic organs
• Types of fistula from vagina to adjacent structures
o Surrounding low T2/STIR fibrous wall
o Vesicovaginal
o Low signal intensity tract with enhancing wall on
o Colovaginal/enterovaginal
o Rectovaginal/anovaginal T1+C
Imaging Pathology
• Communication between vaginal lumen and other • Etiologies include
o Obstetric trauma (prolonged delivery)
pelvic organ on fluoroscopic evaluation
o Vaginography, cystography, barium enema, o Surgery (gynecologic/urologic procedures)
o Inflammation (Crohn)/infection
fistulography
o
• CECT
o
Pelvic malignancy (bladder, cervical, endometrial)
Radiation therapy: Presents up to 20 years after
o Enteric contrast in vagina with bowel-associated
therapy
fistula
o Vesico- or ureterovaginal fistula confirmed with Clinical Issues
contrast in vagina on CT cystography/urography • Clinical symptomology predicts type of vaginal fistula
(Left) Axial CECT with rectal

contrast shows air and a
small amount of extravasated
rectal contrast within the
vaginal lumen , suspicious
for a rectovaginal fistula.
This patient was status post
sigmoidectomy for diverticular
disease. (Right) Frontal image
from a contrast enema in the
the fistula tract extending
between the rectosigmoid
and the vagina . Note
the balloon-tip catheter in the
rectum.

image in the same patient
demonstrates the fistula tract
as a linear hyperintensity
with a faint hypointense
fibrous wall. T2WI FS and
STIR images best demonstrate
the fistula tract. Note the
air within the rectosigmoid
. (Right) Axial T1WI C+
FS MR image from the same
patient demonstrates the fistula
tract as hypointense with
a surrounding enhancing
wall and obscuration of
surrounding fat planes. Note
the rectum and uterine
fundus .
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VAGINAL FISTULA
Vagina and Vulva

o Lateral views best demonstrate fistula
TERMINOLOGY
• Fistulography
Definitions o Cannulation of fistula and injection with water-
• Epithelially lined abnormal communication between soluble contrast
vaginal lumen and adjacent pelvic organs o Often can not be performed as fistula orifice not seen
o Ancillary findings (abscess, anal sphincter damage)
not evaluated
IMAGING
• IVP
General Features o Useful in detection of ureterovaginal fistulas
• Best diagnostic clue o Often performed in conjunction with cystography
o Communication between vaginal lumen and other
CT Findings
pelvic organ on fluoroscopic evaluation
o Abnormal T2/STIR linear hyperintensity extending • NECT
o Larger tracts may be demonstrated as low-
from vagina to adjacent structures
• Morphology
attenuation linear lesions
o Inflammatory changes/fat stranding along fistula
o Simple: Single linear fistula tract o May see fluid, air, or fecal material in vaginal lumen
o Complex: Multiple tracts involving several organs
•
and rectovaginal septum
Types of fistula
o Vesicovaginal
• CECT
o Fistula tract seen as thin linear hypodense collection
o Ureterovaginal
with surrounding enhancement/inflammation
▪ Concurrent vesicovaginal fistulas in 10% of cases o May see associated complications (abscess)
o Urethrovaginal o Multiphase pre- and postcontrast imaging necessary
▪ Associated vesicovaginal fistulas not uncommon o Enteric contrast needed for bowel-associated fistulas
o Colovaginal/enterovaginal
▪ Oral contrast for suspected enterovaginal fistula
▪ Sigmoid colon most commonly involved ▪ Rectal contrast for suspected colovaginal or
▪ Enterovaginal fistulas often secondary to Crohn
rectovaginal fistulas
disease ▪ Presence of enteric contrast in vagina confirmatory
o Rectovaginal/anovaginal o Multiplanar reformatted imaging useful in
▪ Rare; 5% of all anorectal fistulas
identifying fistula
▪ Anal sphincter often involved o CT cystography: Contrast opacification of bladder
Radiographic Findings via Foley or suprapubic catheter
• Imaging evaluation essential to direct intervention ▪ Vesicovaginal fistula confirmed with contrast in
• Several complementary modalities may be necessary to vagina
– Vagina should not opacify in cases of isolated
accurately characterize fistula
ureterovaginal fistula
Fluoroscopic Findings – Consider performing CT cystography prior to
• Vaginography excretion-phase CECT
o Contrast material instilled into vagina via balloon-tip ▪ Consider distending vagina with ultrasound gel for
catheter better visualization of vaginal fistula orifice
o Water soluble contrast material utilized ▪ Image before and after bladder distension
o Lateral view best demonstrates rectovaginal and
MR Findings
• MR: Superior modality owing to multiplanar
vesicovaginal fistulas
o Advantages over contrast enema
▪ Contrast instilled into enclosed space, allowing for capabilities and soft tissue contrast
o Up to 91% sensitive for fistula detection
increased pressure and better fistula opacification
o Better characterization of complex fistula anatomy
▪ Sensitivity of 40-100%
▪ Avoid opacification of bowel loops, which may and complications
o Anal sphincter anatomy/involvement visualized
obscure fistula track and vaginal opacification
o Allows for staging of pelvic tumor if cause of fistula
▪ Multiple/complex fistulas can be recognized
o Balloon may occlude/obscure low fistula tracts • Phased-array coil
o Most fistulous tracts can be well depicted
• Contrast enema (proctography)
o Larger field of view possible
o Water soluble contrast material instilled via balloon
▪ Whole pelvis can be evaluated for complications
tip catheter into rectum/colon
o Lateral rectal filling view may best demonstrate and ancillary findings
rectovaginal fistula • Endoanal/endovaginal coil
o Often fails to opacify fistula o Advantages
▪ Insufficient pressure in bowel lumen to force ▪ High-resolution images of vagina, adjacent organs
contrast through fistula tract into vagina – Improved signal:noise and spatial resolution
▪ Sensitivity of proctography up to 34% ▪ Allows for identification of small fistulous tracts
o Disadvantages
• Cystogram
▪ Limited field of view; may not depict full extent
o Utilized in evaluation for vesicovaginal fistulas
o Water soluble contrast injected into bladder via Foley ▪ Patient discomfort with coil positioning
•
or suprapubic catheter
T1WI
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Vagina and Vulva VAGINAL FISTULA
o Low signal intensity tract; difficult to visualize

CLINICAL ISSUES
• T2WI/STIR
o Fat suppression techniques increase fistula Presentation
conspicuity • Most common signs/symptoms
o High-signal linear tract extending between vagina o Clinical symptomology predicts type of fistula
and communicating organ ▪ Vesicovaginal and ureterovaginal fistulas
▪ Surrounding low-signal fibrous wall – Passage of urine from vagina, recurrent UTI
o Low SI bubbles of air may be seen within high SI tract ▪ Enterovaginal/rectovaginal fistulas
if fistula involves bowel – Passage of air/fecal material from vagina,
o High-signal fluid ± low-signal air in vagina vaginitis
o High SI inflammatory change about fistula tract – Anal incontinence if anal sphincter involved
• T1+C FS o Clinical evaluation includes direct visualization
o Low signal intensity tract with enhancing wall ▪ Colposcopy, cystoscopy, anoscopy, colonoscopy
o Surrounding fat planes obscured ▪ Fistula orifice may be difficult to visualize
o Helps to define underlying malignancy or abscess ▪ Fistula orifice injected with dye (methylene blue)
• Healed fistula tract appears hypointense on T2WI/STIR
Treatment
• Vesicovaginal fistulas may spontaneously heal with
and T1WI secondary to fibrosis
o No post-contrast enhancement
prolonged bladder decompression
Ultrasonographic Findings • Ureterovaginal fistula may be treated with ureteral stent
• Grayscale ultrasound and percutaneous nephrostomy
o Difficult to confidently visualize tract • Surgical resection (fistulectomy)
o Endoluminal techniques may identify fistula • Interposition grafts may be necessary (especially in
▪ Endoanal US can show anal sphincter involvement complex rectovaginal fistulas)
▪ Small field of view; entire fistula may not be seen o Omental interposition grafts
▪ Specific, though not sensitive o Bulbocavernosus-labial (Martius) graft
o Fistulous tract may be seen as thin, hypoechoic linear • Pelvic exenteration for fistulas related to malignancy
band involving vaginal mucosa • Fistulas associated with extensive malignancy or
▪ Fluid in tract = hypoechoic previous radiation therapy may not be amenable to
▪ Air in tract = hyperechoic with "dirty" shadowing surgery
• Best imaging tool DIAGNOSTIC CHECKLIST
o Contrast-enhanced MR is imaging study of choice
• Abnormal linear communication between vagina and
PATHOLOGY adjacent organ
o Linear T2/STIR hyperintensity with post-contrast
General Features
• Etiology
enhancement
o Direct communication on fluoroscopic evaluation
o Obstetric trauma (prolonged delivery) with contrast opacification of fistula tract
▪ Cause of 75% of GU fistulas in developing world
o Surgery (gynecologic/urologic procedures) Reporting Tips
▪ Most common cause in Western populations • Describe type of fistula and involvement of adjacent
o Inflammation/Infection pelvic organs
▪ Diverticulitis • Describe presence and location of fistula tract orifice
▪ Inflammatory bowel disease (Crohn disease) o Superior, mid, or inferior vagina
▪ Postoperative infection o "Clock face" position based on axial imaging
o Pelvic malignancy (bladder, cervical, endometrial) • Report abscess or multiple/complex fistulas
▪ Fistulas develop in up to 2.5% of patients with • Involvement of anal sphincter complex in rectovaginal/
gynecological malignancies anovaginal fistulas
▪ Associated with vesico-/enterovaginal fistulas
▪ Direct extension of primary or recurrent tumor
▪ Complication of tumor resection SELECTED REFERENCES
o Radiation therapy: Presents up to 20 years after 1. Abou-El-Ghar ME et al: Radiological diagnosis of
therapy vesicouterine fistula: role of magnetic resonance imaging. J
o Congenital (very rare) Magn Reson Imaging. 36(2):438-42, 2012
2. Botsikas D et al: A new MDCT technique for the detection
Gross Pathologic & Surgical Features and anatomical exploration of urogenital fistulas. AJR Am J
• Vaginal epithelial defect, mucosal edema/erythema Roentgenol. 198(2):W160-2, 2012
• Fistulous tract may contain fluid, urine, air, blood, pus 3. Narayanan P et al: Fistulas in malignant gynecologic disease:
etiology, imaging, and management. Radiographics.
Microscopic Features 29(4):1073-83, 2009
• Tract is lined by squamous epithelium at vaginal end; 4. Dwarkasing S et al: Anovaginal fistulas: evaluation with
endoanal MR imaging. Radiology. 231(1):123-8, 2004
lining at end organ varies
4 • Tumor cells visible in fistulas related to malignancy
5. Yu NC et al: Fistulas of the genitourinary tract: a radiologic
review. Radiographics. 24(5):1331-52, 2004
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VAGINAL FISTULA
Vagina and Vulva

(Left) Sagittal image from a CT
cystogram demonstrates contrast
opacification of the vagina
via a wide fistula tract with
the bladder . This patient was
status post recent hysterectomy.
(Right) Axial CECT image from
a wide fistulous connection
between the bladder and
vagina. Gynecologic surgery is a
common cause of vaginal fistulas
in the developed world.
(Left) Axial CECT performed with

rectal contrast in a patient with
recurrent pelvic malignancy after
radiation therapy demonstrates
air and contrast in the vagina
, suspicious for a rectovaginal
fistula. (Right) Axial CECT in the
same patient at a higher level
demonstrates the fistula tract
arising from the anterior rectum
. The fistula contains contrast
and a small amount of air. Note
the extensive pelvic sidewall
lymphadenopathy .
(Left) Axial CT cystogram image

shows contrast opacification
of the urinary bladder as well
as the vaginal lumen in a
patient with a vesicovaginal
fistula. There is thickening of
the anterior vaginal wall and
the posterior bladder. Note the
Foley catheter in the bladder
. (Right) Sagittal image
from a CT cystogram in the
contrast-opacified fistula tract
extending between the bladder
and the upper vagina .
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SECTION 5
Ovary

Ovarian Anatomy 5-2
Physiologic and Age-Related Changes

Follicular Cyst 5-12
Corpus Luteal Cyst 5-18
Theca Lutein Cysts 5-24
Hemorrhagic Ovarian Cyst 5-28
Ovarian Inclusion Cyst 5-34
Neoplasms
Ovarian Carcinoma Overview 5-40
Epithelial
Serous Cystadenoma 5-62
Mucinous Cystadenoma 5-68
Adenofibroma and Cystadenofibroma 5-74
Ovarian Serous Carcinoma 5-80
Mucinous Cystadenocarcinoma 5-86
Ovarian Endometrioid Carcinoma 5-92
Ovarian Clear Cell Carcinoma 5-98
Carcinosarcoma (Ovarian Mixed Müllerian Tumor) 5-104
Ovarian Transitional Cell Carcinoma 5-108
Germ Cell
Dermoid (Mature Teratoma) 5-114
Immature Teratoma 5-124
Dysgerminoma 5-128
Ovarian Yolk Sac Tumor 5-132
Ovarian Choriocarcinoma 5-136
Ovarian Carcinoid 5-140
Ovarian Mixed Germ Cell Tumor, Embryonal
Carcinoma and Polyembryoma 5-144
Struma Ovarii 5-148
Obgyne Books Full

Sex Cord-Stromal
Granulosa Cell Tumor 5-154
Fibroma, Thecoma, and Fibrothecoma 5-160
Sertoli-Stromal Cell Tumors 5-166
Sclerosing Stromal Tumor 5-172
Metastases and Hematological
Ovarian Metastases 5-176
Ovarian Lymphoma 5-182
Nonneoplastic Ovarian Lesions

Endometrioma 5-188
Endometriosis 5-198
Ovarian Hyperstimulation Syndrome 5-208
Polycystic Ovary Syndrome 5-212
Peritoneal Inclusion Cysts 5-218
Vascular
Ovarian Vein Thrombosis 5-226
Pelvic Congestion Syndrome 5-232
Acute Adnexal Torsion 5-236
Massive Ovarian Edema and Fibromatosis 5-242
Obgyne Books Full

Ovary OVARIAN ANATOMY
• Proper ovarian (utero-ovarian) ligament attaches

TERMINOLOGY uterine/lower pole of ovary to uterine corpus just
Definitions inferior to tubal insertion
• • Mesosalpinx: Portion of broad ligament between
Paired intraperitoneal reproductive organs that release
ova and produce hormones during reproductive years fallopian tube and proper ovarian ligament/suspensory
ligament of ovary
• Ovary attaches to broad ligament via mesovarium,
GROSS ANATOMY
through which ovarian vasculature enters ovarian
Size hilum
• Premenarche: Mean volume: ~ 3 mL • Not covered by peritoneum, but by germinal
◦ Neonatal: ~ 1 mL; follicles often present due to epithelium
effect of decreasing maternal hormones with
corresponding follicle-stimulating hormone (FSH)
Neurovascular Support
• Arterial supply
release
◦ Principal arterial supply is from ovarian arteries
◦ Pediatric: ~ 0.5-1.5 mL; few follicles
▪ Arise from aorta below renal arteries,
◦ Prepubertal: ~ 1-4 mL; follicles more common
◦ Pubertal: ~ 2-6 mL; follicles common approximately at L1/2 level
▪ Enter ovaries at ovarian hilum
• Premenopausal: Mean volume: ~ 10 mL (4-16 mL)
◦ Minority of arterial supply from uterine artery via
◦ Maximum ovarian volume reached in 3rd decade of
life broad ligament collateral flow
• Venous drainage
◦ Ovarian volumes gradually decline after age 30
◦ Main venous outflow is via ovarian veins
◦ Upper limit of normal ovarian volume: 20 mL
▪ Exit ovary at ovarian hilum
◦ Multiple bilateral developing follicles commonly seen
▪ Venous blood drains into pampiniform plexus near
◦ Ovarian volumes slightly increase during follicular
phase, peaking at ovulation ovarian hilum within mesovarium
▪ Right ovarian vein drains into inferior vein cava at
◦ Slightly larger volumes during pregnancy
• Postmenopausal: Mean volume ~ 6 mL level of renal vasculature
▪ Left ovarian drains into left renal vein
◦ Follicles/cysts less common
◦ Limited venous outflow through parametrial
• Typically symmetrical in size
collateral flow into uterine veins
Morphology • Lymphatic drainage
• Ellipsoid ◦ Ovarian lymphatics follow ovarian veins and drain
• Well marginated into aortocaval and periaortic nodes
• Contain follicles of varying sizes/state of development ◦ Limited lymphatic flow to inguinal/external iliac
in reproductive years nodes via round ligament lymphatics and to internal
◦ Typically measure 2-9 mm in diameter, with iliac/obturator nodes via broad ligament lymphatics
dominant follicles measuring 20-25 mm • Innervation
◦ Cumulus oophorus: Small peripheral septation ◦ Sympathetic innervation mainly via ovarian plexus
variably seen in preovulatory dominant follicle surrounding ovarian vessels
representing ovum and supporting cells ◦ Receives parasympathetic innervation from
◦ Thin, smooth or imperceptible wall splanchnic plexus that travels with ovarian artery
◦ Follicular cysts or corpus luteum often present
Gross Appearance
Positioning • Smooth, dull white
• Positioning is variable, related to age and parturition • Superficial clear cysts/follicles
◦ In neonates, ovaries are normally positioned above • Become more lobulated with age
level of true pelvis
▪ Descend into true pelvis to lie adjacent to uterus as
Microscopic Anatomy
• Outer covering of simple cuboidal epithelium derived
patient ages
◦ In nulliparous patients, ovaries are positioned within from the peritoneum: Germinal (ovarian surface)
ovarian fossa (fossa of Waldeyer) epithelium
• Inner covering of dense connective tissue: Tunica
▪ Along lateral pelvic wall
▪ Bounded anteriorly by obliterated umbilical artery, albuginea
• Ovarian parenchyma divided into outer cortex and
superiorly by external iliac artery, and posteriorly
by ureter and internal iliac artery inner medulla
◦ No clear demarcation
◦ In parous patients, ovarian position can be highly
◦ Cortex: Contains follicles (with associated granulosa
variable
◦ Tubal/upper pole of ovary is enveloped by fallopian cells, theca cells, and oocytes) and connective tissue/
tube fimbriae stroma
◦ Medulla: Richly vascularized stroma
Ligamentous Support • Cortex will contain follicles at different stages of
• Suspensory ligament of ovary attaches tubal/upper folliculogenesis
pole of ovary to pelvic wall, contains ovarian artery and ◦ Primordial follicles (numbering 200,000-400,000
vein at birth): Oocyte with surrounding single layer of
5 epithelial cells
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Obgyne Books Full
OVARIAN ANATOMY
Ovary
◦ Primary follicles • Ovaries are typically well-visualized secondary to
◦ Secondary follicles multiple bilateral follicles
◦ Mature (graafian) follicles • Ovarian artery/vein extend to margin of ovary
◦ Atretic follicles • Ovarian ligaments may be visible as linear intermediate
• Cortex will also contain remnants of ovulatory follicles: signal extending from ovary
Corpus luteum and corpus albicans • T2WI
• Cortex contains supporting hormone-sensitive ◦ Outer cortex: Slightly decreased signal intensity
fibroblasts ◦ Inner medulla: Intermediate to slightly increased
signal intensity
IMAGING ANATOMY ▪ Secondary to more loosely packed cells with
associated vascular stroma
Overview ▪ Signal intensity slightly decreases during
• Initial imaging evaluation of ovaries/adnexa is typically menstruation secondary to decreased water
performed with ultrasound content
• MR is useful for additional evaluation/lesion ◦ Multiple rounded hyperintense developing follicles
characterization if necessary present within cortex in premenopausal patients
▪ May see dominant follicle, follicular cyst, or corpus
Ultrasound
• Typically initial imaging study in evaluation of ovaries luteum
▪ Hemorrhagic cysts will vary in signal intensity
◦ Ovaries seen on transabdominal imaging, but best
◦ In postmenopausal patients, ovaries are of more
evaluated with endovaginal approach
• Located lateral to uterus homogeneous low signal intensity
▪ Small hyperintense cortical cysts are likely to
◦ Often positioned near iliac vasculature, a useful
landmark represent surface inclusion cysts
• T1WI
◦ Ovarian ligaments may be visible when outlined by
◦ Relatively homogeneous low to intermediate signal
free pelvic fluid as linear intermediate echogenicity
◦ Larger cysts/follicles may be appreciated as slightly
structures extending from ovary
• Varied appearance in women of childbearing years hypointense foci
◦ Hemorrhagic cysts appear hyperintense
◦ Central slightly echogenic medulla
• T1WI C+ FS
◦ Multiple cortical follicles of varying size/
◦ Ovarian parenchyma enhances to a lesser degree than
development
▪ Anechoic, simple appearing cysts myometrium
◦ Functional cysts and corpus luteum will show
▪ Thin, smooth imperceptible walls
◦ Corpus luteum may be present peripheral enhancement
• Diffusion-weighted imaging
◦ Hemorrhagic follicular cysts or corpus luteum not
◦ Low signal during menstruation
unusual
◦ May have high signal in periovulatory period
▪ Varied appearance of central blood products
• Postmenopausal ovaries may be difficult to identify
▪ Will resolve over subsequent cycles
◦ Decreased size
• Doppler evaluation
◦ Intermediate to low signal on T1WI
◦ Ovarian arterial and venous waveforms routinely
◦ Relatively hypointense on T2WI
acquired
◦ Fewer/smaller cysts
▪ Diminished or absent flow may be suspicious for
◦ Iso- to hypoenhancing to myometrium
torsion in correct clinical context
◦ Relatively low-velocity, low-resistance arterial CT
waveforms • Not imaging modality of choice in ovarian evaluation,
◦ No flow within follicles
though routinely performed in setting of acute pelvic
◦ Prominent peripheral flow about corpus luteum
pain
("ring of fire") ◦ Multiplanar CT does allow for improved ovarian
• Postmenopausal ovaries imaging when compared to older techniques
◦ Smaller in size, may be difficult to identify • Ovaries are most easily identified by following course
◦ Slightly more hypoechoic
of ovarian vasculature, which terminates at ovarian
◦ Fewer/smaller cysts
margin
▪ Correspond to atretic follicles, surface inclusion • Can be helpful in evaluation of infection (tubo-ovarian
cysts, anovulatory follicles abscess)
◦ May contain punctate peripheral hyperechoic foci • Often appear as ovoid structures of relatively decreased
▪ Correspond to dystrophic calcification associated
attenuation secondary to multiple follicles
with inclusion cysts or atretic follicles • Ovarian ligaments may be visible, especially if outlined
MR by free fluid, as linear soft tissue attenuation structures
• Used to further characterize ovarian masses seen on US extending from ovary
• If present, corpus luteum will show prominent
or when US evaluation is incomplete
◦ Superior soft tissue contrast thickened enhancing wall
• Postmenopausal ovaries may be very difficult to
◦ Multiplanar capabilities
◦ Large field of view identify secondary to atrophy
◦ Featureless with few cysts
◦ Homogeneously soft tissue density 5
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◦ May contain punctate dystrophic calcifications • Migrate to genital ridge around 4-6 weeks of gestation
associated with inclusion cysts or atretic follicles ◦ Located along posterior coelomic cavity, lined by
epithelium (germinal epithelium)
PET ◦ Ovarian surface epithelium arises from germinal
• Low-level increased FDG-18 uptake seen in normal epithelium
ovaries, especially in late luteal and early follicular ◦ Ovarian stroma originates from subcoelomic
phases mesoderm
• More focal and intense uptake seen in presence of ◦ Sex cords (pregranulosa cells) will form from
corpus luteum invaginations of coelomic epithelium
◦ Uptake is unilateral, round or oval in morphology
• In weeks 12-20
◦ SUV values usually > 3
◦ By 3rd month of gestation, distinct cortex and
◦ May mimic ovarian neoplasm
medulla can be recognized
▪ PET studies ideally performed within a week prior
◦ Pregranulosa cells surround immature oocytes to
or a few days after menses, when corpus luteum is form primordial follicles
typically not present ◦ Theca cells, from ovarian stroma, will surround
developing primordial follicles
ANATOMY IMAGING ISSUES ◦ Ovarian vasculature develops
• As gestation continues, ovaries descend into lateral
• Routine evaluation is performed with US (endovaginal pelvis along gubernaculum
◦ Remnant persists as round ligament
technique)
• MR can be performed in equivocal cases when US is
inconclusive or inadequate RELATED REFERENCES
• CT may be performed with suspected tubo-ovarian
1. Ackerman S et al: Ovarian cystic lesions: a current approach
abscess to diagnosis and management. Radiol Clin North Am.
◦ Otherwise, not modality of choice for ovarian
51(6):1067-85, 2013
evaluation 2. Vargas HA et al: MRI of ovarian masses. J Magn Reson
Imaging. 37(2):265-81, 2013
Imaging Approaches 3. Langer JE et al: Imaging of the female pelvis through the life
• When ovaries are difficult to localize, following ovarian cycle. Radiographics. 32(6):1575-97, 2012
vessels into pelvis will help in identification 4. Levine D et al: Management of asymptomatic ovarian and
other adnexal cysts imaged at US: Society of Radiologists in
CLINICAL IMPLICATIONS Ultrasound Consensus Conference Statement. Radiology.
256(3):943-54, 2010
Function & Dysfunction 5. Paulsen D: Histology & Cell Biology: Examination & Board
• Ovaries are endocrine organs that regulate sex hormone Review. 5th ed. New York: McGraw-Hill, 2010
levels and are reproductive organs that release ova 6. Takeuchi M et al: Manifestations of the female reproductive
• organs on MR images: changes induced by various
Menstrual cycle divided into 2 phases: Follicular and
physiologic states. Radiographics. 30(4):1147, 2010
luteal 7. Cunningham F et al: Williams Obstetrics. 23rd ed. New
◦ Follicular phase (1st half of menstrual cycle,
York: McGraw-Hill Medical, 2009
analogous to proliferative phase) 8. Well D et al: Age-related structural and metabolic changes
▪ Pituitary FSH stimulates several ovarian follicles to in the pelvic reproductive end organs. Semin Nucl Med.
mature 37(3):173-84, 2007
▪ 1 follicle becomes dominant 9. Fleischer AC: Recent advances in the sonographic
▪ Follicular granulosa cells produce estradiol under assessment of vascularity and blood flow in gynecologic
conditions. Am J Obstet Gynecol. 193(1):294-301, 2005
FSH stimulation
10. Strickland JL: Ovarian cysts in neonates, children and
▪ Increasing estradiol inhibits further FSH release and
adolescents. Curr Opin Obstet Gynecol. 14(5):459-65, 2002
stimulates release of luteinizing hormone (LH) 11. Togashi K et al: Anatomy and physiology of the female
▪ LH surge induces ovulation pelvis: MR imaging revisited. J Magn Reson Imaging.
◦ Luteal phase (2nd half of menstrual cycle, analogous 13(6):842-9, 2001
to secretory phase) 12. Callen P: Ultrasonography in Obstetrics and Gynecology.
▪ After ovulation, remnants of dominant follicle 3rd ed. Philadelphia: W.B. Saunders, 1994
become corpus luteum (yellow body) and secrete
progesterone under LH stimulation
▪ In absence of pregnancy, corpus luteum will
involute to become corpus albicans (white body)
▪ With pregnancy, corpus luteum will persist into 1st
trimester (as corpus luteum of pregnancy)
▪ Chorionic gonadotropin produced by placenta
prevents regression of corpus luteum
EMBRYOLOGY
Embryologic Events
• Immature oocytes originate from dorsal endoderm of
5 yolk sac
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OVARIAN ANATOMY
Ovary
FOLLICULOGENESIS AND NORMAL ANATOMY
Ampullary segment of
fallopian tube
Tubal fimbriae
Suspensory ligament of
ovary with ovarian artery Proper ovarian ligament
and vein
Fallopian tube, ampullary

segment
Fallopian tube, isthmic
segment
Suspensory ligament of
ovary
Mesosalpinx
Proper ovarian ligament

Tubal fimbriae
Mesovarium Ovary, with follicles

at different stages of
Broad ligament development
Distal ureter
(Top) Illustration demonstrates the ovary in various states of folliculogenesis. Note the relationship of the ovary with its supporting ligaments.
(Bottom) Illustration of the adnexa demonstrates normal ligamentous anatomy and anatomic relationships. Note the ovarian vasculature traveling
with the suspensory ligament of the ovary and entering the ovarian hilum via the mesovarium.
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OVARIAN ANATOMY, ULTRASOUND
Urinary bladder
Echogenic IUD within

endometrial lumen
Central ovarian medulla
Uterine myometrium
Dominant follicle within

peripheral ovarian cortex
Outer ovarian cortex
Normal follicle, positioned

within cortex
(Top) Transabdominal image of the pelvis demonstrates a normal sonographic appearance of the ovary. The ovary is positioned along the pelvic
sidewall and demonstrates multiple follicles of varying degrees of development. (Bottom) Endovaginal ultrasound image demonstrates a normal
ovarian appearance. Note the multiple follicles of varying degrees of development positioned within the peripheral ovarian cortex. The central
ovarian medulla is typically slightly more echogenic than the cortex.
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OVARIAN ANATOMY
Ovary
OVARIAN ANATOMY, ULTRASOUND
Ovarian parenchyma with

smaller developing follicles
Follicular cyst
Cumulus oophorus
Ovarian parenchyma
Physiologic follicle
Thick-walled corpus luteum
"Ring of fire" peripheral

color flow
(Top) Endovaginal ultrasound of the ovary demonstrates a dominant follicular cyst. Note the small, thin peripheral septation, which represents
a cumulus oophorus. A peripheral rind of compressed ovarian parenchyma is present, with additional smaller physiologic follicles. (Bottom)
Composite endovaginal ultrasound image (grayscale above, color Doppler below) of the ovary demonstrates a thick-walled cyst, consistent with
a corpus luteum. On color Doppler ultrasound evaluation, prominent peripheral vascular flow is noted, the so-called ring of fire appearance. A
corpus luteum is a normal finding in a patient of childbearing age.
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OVARIAN ANATOMY, MR
Uterine fundus Endometrium
Dominant follicle
Peripheral ovarian cortex

Uterine myometrium
Round ligament
External iliac vasculature Hypoenhancing ovarian

parenchyma
Nonenhancing dominant
follicle
Internal iliac vasculature
(Top) Axial T2WI through the pelvis demonstrates a normal appearance of the ovaries in a premenopausal woman. The ovaries have multiple
physiologic follicles of varying degrees of development. The outer ovarian cortex is slightly hypointense, and the inner medulla is relatively
hyperintense. (Bottom) Axial T1WI C+ MR from the same patient shows the normal post-contrast appearance of premenopausal ovaries. The
ovarian parenchyma is hypointense/hypoenhancing when compared to the uterine myometrium. Note the positioning of the ovaries within the
ovarian fossae along the pelvic sidewall, between the internal and external iliac vasculature.
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OVARIAN ANATOMY
Ovary
OVARIAN ANATOMY, MR
Endometrium
Right ovary
Myometrial junctional zone
Thick-walled, irregular
corpus luteum
Free fluid within cul-de-sac
External iliac vasculature
Enhancing myometrium
Enhancing irregular wall of

corpus luteum
Internal iliac vasculature
(Top) Axial T2WI MR shows a normal appearance of the ovary in a premenopausal patient. There is an irregular, thick-walled corpus luteum
within the ovary, a normal finding. Additional physiologic follicles are present as well. (Bottom) Axial T1WI C+ MR from the same patient
demonstrates avid enhancement of the irregular, thickened corpus luteum wall. The remainder of the ovarian parenchyma is relatively
hypoenhancing.
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OVARIAN ANATOMY, CT
Urinary bladder
Uterine fundus
External iliac vasculature
Right ovary
Left ovary
Internal iliac vasculature,

anterior division
Uterine body
Right ovary
Left ovary
(Top) Axial CECT in a premenopausal patient shows a normal CT appearance of the ovaries. The ovaries appear slightly hypodense secondary
to multiple underlying follicles of varying degrees of development. (Bottom) Coronal CECT in the same patient shows a normal appearance of
premenopausal ovaries. The ovaries are positioned in the ovarian fossae along the pelvic sidewall. In multiparous patients, the ovaries are more
variable in positioning.
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OVARIAN ANATOMY
Ovary
OVARIAN ANATOMY, CT AND PET/CT
Left external iliac

vasculature
Right ovary
Left ovary
Right external iliac
vasculature
Right ovary with dominant

follicle Left ovary
Bladder activity
Left ovary
Right ovary
(Top) Axial CECT in a postmenopausal patient shows a normal appearance of the ovaries. Postmenopausal ovaries are small, atrophic, and
relatively featureless. The ovaries can be difficult to identify and are typically positioned along the external iliac vasculature, and the ovarian
vasculature can be traced to their margins. (Bottom) Composite image from a PET/CT study in a premenopausal patient (anatomic CT above,
fused PET/CT below) shows ovaries demonstrating normal low-level physiologic uptake, as seen on the fused image. More focal and intense
uptake can be seen in the presence of a corpus luteum, which may simulate pathology. PET studies are ideally performed within a week prior to
or a few days after menses, when a corpus luteum is unlikely to be present.
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Ovary FOLLICULAR CYST
Key Facts
Terminology • CECT: Fluid density ovarian cyst without central
• Hormone-dependent functional ovarian cyst enhancement
• Transvaginal US with color Doppler is preferred
• Result of arrested follicular development with imaging modality because of its wide availability and
subsequent cyst formation
cost effectiveness
• Well-marginated round/oval cyst with a thin wall • Endometrioma
o Typically 2-8 cm, solitary
• Peripheral rim of compressed ovarian parenchyma, • Corpus luteal cyst
often with other smaller developing follicles • Paratubal (paraovarian) cyst
• US: Anechoic, avascular, simple-appearing ovarian cyst • Surface epithelial tumor
o Varied appearance of internal contents if
Clinical Issues
•
hemorrhagic
MR: T1 hypointense, T2 hyperintense simple cyst • Majority of simple ovarian cysts in premenopausal
patients are developing follicles or follicular cysts
o No enhancement of central contents o Typically regress spontaneously in 2 cycles
o Thin, smooth enhancing wall without nodularity or
• Most are asymptomatic
papillary projections
o Varied central signal if hemorrhagic • Typically, no treatment is indicated

ultrasound shows a typical
ovarian follicular cyst
with a thin wall and anechoic
simple-appearing central
contents. Note the posterior
(Right) Coronal CECT shows a
dominant left ovarian follicular
cyst , with a few smaller
follicles noted as well. On
CT, a simple follicular cyst
will be rounded/oval, well-
marginated, and measure fluid
attenuation.

demonstrates a well-
marginated homogeneously
hyperintense cystic ovarian
lesion , which is consistent
with a follicular cyst. This
is a normal finding in a
premenopausal patient.
the follicular cyst to have
a thin enhancing wall .
Irregular septations or mural
nodularity may be suspicious
for neoplasm.
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FOLLICULAR CYST
Ovary
o Peripheral rim of compressed ovarian parenchyma,
TERMINOLOGY
often with other smaller developing follicles
Abbreviations •Pulsed Doppler
• Follicular cyst (FC) o Low-resistance peripheral arterial flow
Synonyms •Color Doppler

o Early follicular phase: Scant peripheral flow
• Physiologic cyst o Late follicular phase (as ovulation approaches):
• Dominant follicle Increasing peripheral Doppler flow that approaches a
Definitions "ring of fire" appearance
o Hemorrhagic cyst contents do not demonstrate flow
• Hormone-dependent functional ovarian cyst
• Develops during follicular phase of menstrual cycle and with Doppler imaging
▪ Solid-appearing mural nodule in hemorrhagic cyst
persists into luteal phase
is avascular
•Power Doppler
IMAGING o Cyst wall appears more vascularized as ovulation
approaches: "Ring of fire" appearance
General Features o Solid-appearing mural nodule in hemorrhagic cyst is
• Best diagnostic clue avascular
o Simple-appearing ovarian cyst that resolves over time
o Majority of simple ovarian cysts in premenopausal MR Findings
patients are normal follicles or FC • T1WI
• Location o Simple-appearing cyst in most cases
o Cortex of ovary ▪ Cyst wall: Smooth, slightly hypointense to ovarian
• Size stroma
▪ Cyst content: Low signal intensity (simple fluid)
o Typically 2-8 cm
▪ Usually do not exceed 5 cm o Cyst content may vary if complicated by hemorrhage
o Rarely, can be larger •T2WI
• Morphology o Simple-appearing cyst in most cases
▪ Cyst wall: Intermediate signal intensity, smooth
o Rounded or oval-shaped, depending on number of
adjacent cysts ▪ Cyst content: High signal intensity (simple fluid)
o Well marginated o Cyst content may vary if complicated by hemorrhage
o Smooth, thin wall ▪ Should not show T2 shading seen in
o Typically solitary endometriomas (which is result of repeated
o May be complicated by hemorrhage bleeding)
▪ Varied imaging appearance of internal contents o Cumulus oophorus
o Cumulus oophorus ▪ Small, thin peripheral septation, which can be seen
▪ Cluster of cells that surrounds oocyte within preceding ovulation
preovulatory FC and after ovulation o Peripheral rim of compressed ovarian parenchyma,
▪ Can be seen on imaging as a small, thin septation often with other smaller developing follicles
along periphery of otherwise simple FC •T1WI C+ FS
▪ Best seen immediately preceding ovulation o No enhancement of central contents
o FC wall shows smooth linear enhancement
Ultrasonographic Findings ▪ Early follicular phase: Minimal enhancement
• Grayscale ultrasound ▪ Late follicular phase (as ovulation approaches):
o Common appearance: Thin-walled unilocular Increasing wall enhancement with slight
anechoic cyst thickening
▪ Well marginated, round or oval o Cumulus oophorus
▪ Smooth, thin walls ▪ Peripheral septation will show smooth
▪ Posterior acoustic enhancement enhancement
o Less commonly, may be hemorrhagic with varied
appearance of internal contents CT Findings
▪ Heterogeneous echogenic content • NECT
▪ Fine, lace-like linear internal echoes o Most common appearance: Thin-walled adnexal cyst
▪ Retracted clot with concave or convex border with fluid attenuation content
▪ Solid-appearing mural nodule o Less common appearance: Thin to thick walled ±
▪ Fluid-fluid level hemorrhagic content
▪ Diffuse low-level echoes ▪ May appear as soft tissue density or hyperdense
– More commonly seen with endometriomas •CECT
▪ Will still demonstrate posterior acoustic o Thin, smooth enhancing wall
enhancement o Central cyst contents should show no enhancement
o Cumulus oophorus o Cumulus oophorus
▪ Small, thin peripheral echogenic septation, which ▪ Peripheral septation will show smooth
can be seen preceding ovulation enhancement
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o Peripheral rim of compressed ovarian parenchyma, Surface Epithelial Tumor

often with other smaller developing follicles • Irregular/thickened vascularized septa
Imaging Recommendations • Vascular mural nodule or solid component
• Best imaging tool • "Ring of fire" unusual
o Transvaginal ultrasound (TVUS) with color Doppler • Serous cystadenoma may appear as persistent simple
is preferred imaging modality because of its wide ovarian cyst
availability and cost effectiveness Ovarian Hyperstimulation Syndrome
▪ Most FC are accurately characterized by TVUS
▪ Common, normal, and expected finding in • Multiple bilateral enlarged ovarian follicles
premenopausal women • Result of hormonal stimulation in fertility treatment
▪ FC measuring ≤ 3 cm require no follow-up • Ascites and pleural effusion may also be present
– Inclusion of description in report may not be Ovarian Abscess
necessary
▪ Simple cyst measuring ≤ 5 cm or a premenopausal
• Complicated ovarian/adnexal cystic lesion
• Clinical and laboratory signs suggestive of infection
• Inflamed adnexal fat
patient likely represents FC
– Follow-up may not be necessary
▪ Simple cysts > 5 cm but ≤ 7 cm require yearly US • Thick-walled fallopian tube ± pyosalpinx
follow-up Ovarian Dermoid
▪ Simple cysts > 7 cm require further
characterization with MR or surgical evaluation
• Classically appears as mixed cystic-solid complex
ovarian mass
– Complete evaluation of large lesions may be
• Fat content confirms diagnosis
difficult on US
▪ Classic hemorrhagic cyst in premenopausal patient • No significant mural vascularity
measuring ≤ 5 cm may not require follow-up
▪ Hemorrhagic cysts > 5 cm require 6-12 week US PATHOLOGY
follow-up
▪ Cyst that is not classic for but likely to represent General Features
hemorrhagic cyst requires 6-12 week US follow-up • Etiology
regardless of size o FC result from arrested development/nonrupture of
– Hemorrhagic FC should resolve normal physiologic follicle
– Continued follow-up (US or MR) required for o Follicular phase (1st half of menstrual cycle)
persistent lesions ▪ Follicle-stimulating hormone (FSH) from pituitary
o MR can be used to characterize indeterminate stimulates several ovarian follicles to mature
lesions, but usually not necessary to diagnose FC ▪ 1 follicle becomes dominant
– Secretes estradiol, which inhibits further FSH
release and stimulates release of pituitary
DIFFERENTIAL DIAGNOSIS luteinizing hormone (LH)
Endometrioma – LH surge induces ovulation
▪ If this process arrests before ovulation, follicle will
• Hypovascular cyst wall
• Uniform low-level echoes remain unruptured
– Will enlarge to form FC that persists into luteal
• Hyperechoic mural foci (hemosiderin, calcification)
• High signal intensity T1WI
phase (2nd half of menstrual cycle)
• Low signal intensity T2WI (shading) Gross Pathologic & Surgical Features
• Persists on serial imaging • Thin-walled, smooth, unilocular ovarian cyst
o Contains clear to straw-colored fluid
Corpus Luteal Cyst o Clotted contents if hemorrhagic
• Hormone-secreting cyst with thickened crenulated • No mural nodules or papillary projections
enhancing wall
• May show evidence of internal hemorrhage Microscopic Features
• Residua of follicle that persists after ovulation to • Histologic features
prepare endometrium for implantation and support o Inner layer of granulosa cells
early pregnancy o Outer layer of theca interna cells
• Will resolve • Cytologic features
o Granulosa and theca cells are often luteinized
Paratubal (Paraovarian) Cyst ▪ Cytoplasm is eosinophilic to clear
• Simple adnexal cyst separate form ovary ▪ Round nuclei with central nucleoli
• Persist on serial imaging
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FOLLICULAR CYST
Ovary
6. Brown DL et al: Adnexal masses: US characterization and
CLINICAL ISSUES reporting. Radiology. 254(2):342-54, 2010
Presentation 7. Heilbrun ME et al: Imaging of benign adnexal masses:
• Most common signs/symptoms characteristic presentations on ultrasound, computed

tomography, and magnetic resonance imaging. Top Magn
o Most are asymptomatic Reson Imaging. 21(4):213-23, 2010
• Other signs/symptoms 8. Levine D et al: Management of asymptomatic ovarian and
o Pain other adnexal cysts imaged at US: Society of Radiologists in
o Palpable adnexal mass Ultrasound Consensus Conference Statement. Radiology.
o Rarely can present with hemorrhage, rupture, and 256(3):943-54, 2010
9. Takeuchi M et al: Manifestations of the female reproductive
hemoperitoneum organs on MR images: changes induced by various
▪ Acute pelvic pain with tachycardia/hypovolemia physiologic states. Radiographics. 30(4):1147, 2010
Demographics 10. Potter AW et al: US and CT evaluation of acute pelvic pain of
• Age gynecologic origin in nonpregnant premenopausal patients.

Radiographics. 28(6):1645-59, 2008
o Present in ovaries from menarche until menopause 11. Shwayder JM: Pelvic pain, adnexal masses, and ultrasound.
▪ May be seen in early postmenopause secondary to Semin Reprod Med. 26(3):252-65, 2008
sporadic ovulation 12. Tamai K et al: MR features of physiologic and benign
• Epidemiology conditions of the ovary. Eur Radiol. 16(12):2700-11, 2006
o Common normal finding in women of childbearing 13. Patel MD et al: The likelihood ratio of sonographic findings
for the diagnosis of hemorrhagic ovarian cysts. J Ultrasound
age in absence of hormonal suppression Med. 24(5):607-14; quiz 615, 2005
Natural History & Prognosis 14. Swire MN et al: Various sonographic appearances of
• Physiologic process with spontaneous resolution the hemorrhagic corpus luteum cyst. Ultrasound Q.
20(2):45-58, 2004
o Majority regress within 2 cycles (1-2 months) 15. Guerriero S et al: The diagnosis of functional ovarian cysts
o Persistence in minority of cases using transvaginal ultrasound combined with clinical
parameters, CA125 determinations, and color Doppler. Eur J
Treatment
• Typically, no treatment is indicated
Obstet Gynecol Reprod Biol. 110(1):83-8, 2003
16. Jain KA: Sonographic spectrum of hemorrhagic ovarian
• Expectant management cysts. J Ultrasound Med. 21(8):879-86, 2002
o Follow-up based on FC size and presence of 17. Miele V et al: Hemoperitoneum following ovarian cyst
rupture: CT usefulness in the diagnosis. Radiol Med
hemorrhage
• Estrogen-progesterone therapy may be indicated for 18.
(Torino). 104(4):316-21, 2002
Pretorius ES et al: Magnetic resonance imaging of the ovary.
persistent follicles
•
Top Magn Reson Imaging. 12(2):131-46, 2001
Rarely, transabdominal or transvaginal aspiration of 19. Dill-Macky MJ et al: Ovarian sonography: In
symptomatic FC may be indicated if no response to Ultrasonography in Obstetrics and Gynecology. 4th ed.
hormone therapy Philadelphia: Saunders. 863-4, 2000
20. MacKenna A et al: Clinical management of functional
ovarian cysts: a prospective and randomized study. Hum
DIAGNOSTIC CHECKLIST Reprod. 15(12):2567-9, 2000
21. Borgfeldt C et al: Transvaginal sonographic ovarian findings
Consider in a random sample of women 25-40 years old. Ultrasound
• FC is a common benign finding in premenopausal Obstet Gynecol. 13(5):345-50, 1999
patients 22. Hertzberg BS et al: Adnexal ring sign and hemoperitoneum
caused by hemorrhagic ovarian cyst: pitfall in the
Image Interpretation Pearls sonographic diagnosis of ectopic pregnancy. AJR Am J
• Simple functional ovarian cyst that resolves over time Roentgenol. 173(5):1301-2, 1999
• May show evidence of internal hemorrhage 23. Hertzberg BS et al: Ovarian cyst rupture causing
hemoperitoneum: imaging features and the potential for
Reporting Tips misdiagnosis. Abdom Imaging. 24(3):304-8, 1999
• Follow-up interval, if indicated, should be described in 24. Guerriero S et al: Sonographic differential diagnosis of
persistent ovarian cysts. Ultrasound Obstet Gynecol.
report
12(1):74-5, 1998
25. Sickler GK et al: Free echogenic pelvic fluid: correlation with
SELECTED REFERENCES hemoperitoneum. J Ultrasound Med. 17(7):431-5, 1998
26. Outwater EK et al: Normal ovaries and functional cysts: MR
1. Ackerman S et al: Ovarian cystic lesions: a current approach appearance. Radiology. 198(2):397-402, 1996
to diagnosis and management. Radiol Clin North Am. 27. Atri M et al: Endovaginal sonographic appearance of benign
51(6):1067-85, 2013 ovarian masses. Radiographics. 14(4):747-60; discussion
2. Ross EK et al: Incidental ovarian cysts: When to reassure, 761-2, 1994
when to reassess, when to refer. Cleve Clin J Med. 28. Okai T et al: Transvaginal sonographic appearance
80(8):503-14, 2013 of hemorrhagic functional ovarian cysts and their
3. Vargas HA et al: MRI of ovarian masses. J Magn Reson spontaneous regression. Int J Gynaecol Obstet. 44(1):47-52,
Imaging. 37(2):265-81, 2013 1994
4. Laing FC et al: US of the ovary and adnexa: to worry or not 29. Bass IS et al: The sonographic appearance of the
to worry? Radiographics. 32(6):1621-39; discussion 1640-2, hemorrhagic ovarian cyst in adolescents. J Ultrasound Med.
2012 3(11):509-13, 1984
5. Langer JE et al: Imaging of the female pelvis through the life
cycle. Radiographics. 32(6):1575-97, 2012
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Doppler ultrasound shows a
hypoechoic cystic lesion
with thin lace-like internal
echoes . Note the posterior
acoustic enhancement.
This appearance is most
suggestive of a hemorrhagic
follicular cyst. (Right)
same patient shows scant
peripheral color flow without
internal vascularity. In a
premenopausal patient, a
classic hemorrhagic follicular
cyst may not require follow-up
imaging.

premenopausal patient
shows a well-marginated fluid
attenuation simple left adnexal
cyst , most suggestive
of a follicular cyst. (Right)
Coronal CECT image from
simple left adnexal cyst ,
most consistent with a normal
follicular cyst. There should
be no irregular thickened
septation or mural nodularity.

shows a homogeneously
hyperintense left ovarian
cyst , most consistent
with a follicular cyst in a
premenopausal patient. Note a
single thin peripheral septation
. (Right) Coronal T1 C+ FS
the follicular cyst to have
a thin, smooth enhancing wall
without mural nodularity. A
single thin peripheral septation
is again noted. This is
a typical appearance for a
cumulus oophorus.
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FOLLICULAR CYST
Ovary
image shows a dominant ovarian
follicular cyst , which is
well marginated and anechoic.
enhancement . This is a
normal, expected finding in
a premenopausal patient.
(Right) Composite transvaginal
ultrasound image from a different
patient shows a hemorrhagic
follicular cyst . On the upper
image, note the eccentric
retracting blood products ,
which show no internal color
flow on Doppler imaging (lower
image).

a dominant right ovarian
homogeneously hyperintense
follicular cyst , with a few
smaller follicles noted as well.
Note the enlarged fibroid uterus
same patient shows the follicular
cyst to be very slightly
hyperintense when compared
to the ovarian parenchyma.
This suggests an element of
hemorrhage.

image shows an ovoid anechoic
ovarian follicular cyst ,a
normal and expected finding
in premenopausal patients.
Note the single thin peripheral
septation , suggestive of a
cumulus oophorus. (Right)
ultrasound image in a different
patient shows an avascular
hypoechoic follicular cyst
with low-level internal
echoes. This appearance may be
suggestive of an endometrioma,
though it can be seen in
hemorrhagic follicular cysts.
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Ovary CORPUS LUTEAL CYST
Key Facts
Terminology o If hemorrhagic, central blood products will vary in
• Cystic dilation of normal, physiologic corpus luteum appearance
o Posterior acoustic enhancement
Imaging o Prominent vascular flow within cyst wall with "ring
• Corpus luteum cysts are common incidental findings of fire" appearance
o Unilocular cyst with thickened irregular/crenelated • CL is typically < 3 cm
vascularized wall o US follow-up may be warranted for larger (> 5 cm) or
o Can mimic a vascular solid mass when collapsed atypical cases
• CECT
o Ovarian cyst with irregular enhancing wall
• • Ectopic pregnancy
• Endometrioma
MR
o Thickened irregular enhancing cyst wall
o Cyst contents vary in signal intensity depending on • Primary ovarian neoplasm
presence of hemorrhage • Ovarian abscess
o No internal enhancing papillary projections or
Clinical Issues
• US
mural nodularity
• Most commonly asymptomatic, though can present
with acute pelvic pain/hemoperitoneum if ruptured
o Anechoic cyst with thickened echogenic wall
• Majority regress spontaneously in 2 months

of the ovary demonstrates a
thick-walled cyst with a
few low-level internal echoes
. In a premenopausal
patient, this is most likely to
be a normal corpus luteum
cyst with a small amount
of hemorrhage. (Right)
Color Doppler transvaginal
demonstrates prominent
vascularity about the
periphery of the cyst, the so-
called ring of fire appearance
of a corpus luteum.

shows a thick-walled cyst in
the right ovary . Note the
subtle hypointensity of the
thickened wall , typical for
a corpus luteum cyst. Note
the normal uterus . (Right)
thickened corpus luteum
cyst wall , a common and
normal finding. Note the
normal uterus .
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CORPUS LUTEAL CYST
Ovary
o Associated hyperdense ascites/hemoperitoneum
TERMINOLOGY
present when ruptured
Abbreviations ▪ May see active extravasation of IV contrast with
• Corpus luteal cyst (CLC) ongoing bleeding
Synonyms MR Findings
• Cystic corpus luteum (CL) • T1WI
• Luteal cyst o Cyst wall: Thickened and irregular with slightly
• Functional cyst increased signal intensity
o Cyst contents: Variable signal intensity
• Luteinized functional cyst ▪ Nonhemorrhagic: Low central signal intensity
Definitions ▪ Hemorrhagic: Variable signal intensity with
• Cystic dilation of normal, physiologic CL during luteal/ possible fluid-fluid level
secretory phase of menstrual cycle • T2WI
• Functional cyst that secrets hormones to prepare for o Cyst wall: Thickened with intermediate to low signal
implantation and support early pregnancy intensity
o Cyst contents: Variable signal intensity
▪ Nonhemorrhagic: High signal intensity centrally
IMAGING ▪ Hemorrhagic: Central signal intensity is
General Features variable depending on age of hemorrhage; may
• Best diagnostic clue demonstrate a fluid level or debris
▪ T2 "shading", as seen in endometriomas, is not
o Thick-walled unilocular cyst with thick irregular/
crenelated vascularized wall classic but can be seen
o May mimic vascular solid mass when collapsed or o May appear as variable signal solid mass if collapsed/
regressed
•
involuted
• Location T1WI C+ FS
o Thickened cyst wall shows intense and early
o CLCs originate from ovarian cortex
• Size enhancement
▪ Irregular/crenulated contour
o CL is typically < 3 cm
▪ No internal enhancing papillary projections or
▪ CLC is technically defined as cystic dilation of CL >
mural nodularity
3 cm o May appear as intensely enhancing solid-appearing
▪ In practice, any cystic CL (regardless of size) is
mass if collapsed/regressed
often described as CLC
o Can grow up to 8 cm Ultrasonographic Findings
• Morphology • Best characterized on endovaginal evaluation, though
o Thick-walled cystic mass may be visible transabdominally
▪ Rounded or oval, well marginated • Varied appearance on grayscale imaging depending on
▪ Thickened, luteinized wall demonstrates an presence of hemorrhage and level of cyst involution
irregular or crenulated contour o Appears as thick-walled anechoic cyst in absence of
– CLC walls measure 1-5 mm in thickness hemorrhage
▪ With involution, CLC decreases in size with ▪ Echogenic, thickened wall
increasing wall irregularity o If hemorrhagic, will demonstrate central blood
o May mimic solid mass when hemorrhagic or products that vary in appearance
collapsed/involuted ▪ Thin lace-like linear echoes
▪ Account for majority of solid-appearing masses in ▪ Retracted clot with concave or convex border
premenopausal women ▪ Fluid-fluid level
▪ Homogeneous low-level echoes (more typical of
CT Findings
• NECT
endometriomas)
o Demonstrates posterior acoustic enhancement
o Appears as nonspecific adnexal cyst o May simulate solid mass as cyst collapses and
o May be hyperdense if hemorrhagic, simulating solid
involutes
adnexal mass o Hemoperitoneum due to cyst rupture is uncommon
• CECT ▪ Will see complicated free pelvic fluid with internal
o Thick-walled enhancing cyst echoes
▪ Wall enhances whereas central contents are • Color Doppler
avascular and do not enhance o Prominent vascular flow within cyst wall
▪ Irregular or crenulated wall contour ▪ Results in "ring of fire" appearance
▪ No internal enhancing papillary projections or o There should be no central color flow or vascularized
mural nodularity mural nodularity
o May mimic small enhancing mass when collapsed or
involuted
• Pulsed Doppler
o Low-resistance flow in cyst wall
o Hyperdense cyst (30-100 HU) if hemorrhagic
▪ May see a fluid-fluid level Nuclear Medicine Findings
• PET/CT 5
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o CLC will demonstrate unilateral focal rounded Theca Lutein Cysts/Hyperreactio Luteinalis
increased uptake corresponding to ovary
o Optimally, PET/CT studies should be performed
• Variant of CLC with multiple large bilateral functional
ovarian cysts
within a week of or shortly after menses to minimize • Due to overstimulation by high levels of β-hCG
physiologic uptake
• Seen in trophoblastic disease or exogenous β-hCG for
Imaging Recommendations fertility treatment
o Most cases diagnosed by endovaginal US PATHOLOGY
▪ Endovaginal US is typically first-line modality in
evaluation of ovarian cystic lesions Gross Pathologic & Surgical Features
o US follow-up for larger (> 5 cm) or atypical cases • Round, yellow structure with lobulated margins
▪ Follow-up in 6 weeks during early follicular phase o Mature CL are typically 1.5-2.5 cm
o CLCs are common incidental findings on routine CT • Cyst wall is thickened and irregular
and MR studies • Central cyst contents are typically serous or
serosanguineous
DIFFERENTIAL DIAGNOSIS Microscopic Features
Ectopic Pregnancy • CLC wall becomes "luteinized" and contains 3 main cell
• Extrauterine gestational sac, most commonly tubal in
types
o Granulosa lutein cells
origin ▪ Large polygonal cells with abundant pale and
• Thick-walled adnexal cyst with prominent peripheral eosinophilic cytoplasm
vascularity ▪ May contain numerous small lipid droplets
• Internal yolk sac and embryonic pole with cardiac ▪ Nucleus is rounded and may contain 1 or 2 large
activity on M-mode US
• Positive serum human chorionic gonadotropin (β-
nucleoli
▪ Produce progesterone, estrogen, and inhibin A
hCG) is key in diagnosis o Theca lutein cells
• True ovarian ectopic pregnancies are exceedingly rare ▪ Smaller cells with a round to oval nucleus and
Endometrioma single nucleolus
▪ Darkly staining cytoplasm with lipid droplets
• Hypovascular cyst wall ▪ Typically reside within theca interna
• Uniform low-level echoes on US ▪ Produce androgens, estrogen, and progesterone
• Hyperechoic mural foci (hemosiderin, calcification) o K cells
• High signal intensity T1WI with "shading" on T2WI ▪ Less common cell type that is typically found in
• Persists upon serial imaging theca interna
Surface Epithelial Tumor ▪ Stellate shape
▪ Irregular hyperchromatic nucleus
• Vascular thickened/irregular septations &/or mural • Theca interna: Continuous layer of cells about outer
nodularity
• "Ring of fire" appearance of prominent peripheral circumference of CLC
o Contain vascular septae that contribute to wall
vascularity is unusual
vascularity
Sex-Cord Stromal Tumor
• Can appear solid and vascular when small, mimicking CLINICAL ISSUES
collapsed/regressed CLC
• Cystic changes in larger tumors Presentation
• No resolution on short-term follow-up • Most common signs/symptoms
o Most commonly asymptomatic
Germ Cell Tumor o May present with acute pelvic pain, especially when
• Can appear solid and vascular when small, mimicking hemorrhagic
collapsed/regressed CLC
• Cystic changes in larger tumors • Other signs/symptoms
o Rarely presents as palpable adnexal mass with pelvic
• No resolution on short-term follow-up pressure
Ovarian Abscess o May present with hemoperitoneum and hypotension
• Clinical history and laboratory findings suggest with rupture
▪ Increased vascularity of CLC wall may predispose
infection
• Inflamed adnexal fat to hemorrhage and rupture
o When large, can serve as lead point for adnexal
• Thick-walled fallopian tube ± pyosalpinx torsion
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Ovary
Demographics • Simple or hemorrhagic cyst with thick irregular
• Age enhancing wall on CT or MR
o Seen during reproductive years
o May be seen in early postmenopause/perimenopause SELECTED REFERENCES
secondary to sporadic ovulation
1. Ackerman S et al: Ovarian cystic lesions: a current approach
Natural History & Prognosis to diagnosis and management. Radiol Clin North Am.
• Majority regress spontaneously in 2 months 2.
51(6):1067-85, 2013
Ross EK et al: Incidental ovarian cysts: When to reassure,
o Complete resolution in majority of patients,
when to reassess, when to refer. Cleve Clin J Med.
persistence in minority 80(8):503-14, 2013
o Remnants of prior CLC may be seen on US as small 3. Laing FC et al: US of the ovary and adnexa: to worry or not
complicated cyst (atretic CLC) to worry? Radiographics. 32(6):1621-39; discussion 1640-2,
• CLC is part of normal ovarian cycle 2012
o Follicular phase (1st half of menstrual cycle) 4. Langer JE et al: Imaging of the female pelvis through the life
▪ Pituitary follicle-stimulating hormone (FSH) cycle. Radiographics. 32(6):1575-97, 2012
5. Parker RA 3rd et al: MR imaging findings of ectopic
stimulates several ovarian follicles to mature pregnancy: a pictorial review. Radiographics. 32(5):1445-60;
▪ 1 follicle becomes dominant discussion 1460-2, 2012
– Follicular granulosa cells produce estradiol under 6. Brown DL et al: Adnexal masses: US characterization and
FSH stimulation reporting. Radiology. 254(2):342-54, 2010
– Increasing estradiol inhibits further FSH release 7. Heilbrun ME et al: Imaging of benign adnexal masses:
and stimulates release of luteinizing hormone characteristic presentations on ultrasound, computed
(LH) tomography, and magnetic resonance imaging. Top Magn
– LH surge induces ovulation Reson Imaging. 21(4):213-23, 2010
8. Levine D et al: Management of asymptomatic ovarian and
o Luteal phase (2nd half of menstrual cycle)
other adnexal cysts imaged at US: Society of Radiologists in
▪ After ovulation, remnants of dominant follicle Ultrasound Consensus Conference Statement. Radiology.
become CL (yellow body) and secrete progesterone 256(3):943-54, 2010
under LH stimulation 9. Shin YM et al: Computed tomography appearance of
▪ CL wall undergoes cellular hypertrophy and ovarian cysts with hyperenhancing rim during the
vascularization, with luteinization of granulosa menstrual cycle in women of different ages. J Comput Assist
cells Tomogr. 34(4):532-6, 2010
▪ CL increase in size for 1st week after ovulation, 10. Spencer JA et al: MR imaging of the sonographically
indeterminate adnexal mass. Radiology. 256(3):677-94,
then begins to regress 2010
▪ In absence of pregnancy, CL will involute to 11. Takeuchi M et al: Manifestations of the female reproductive
become corpus albicans (white body) organs on MR images: changes induced by various
▪ With pregnancy, CL will persist into 1st trimester physiologic states. Radiographics. 30(4):1147, 2010
(as CL of pregnancy) 12. Devoto L et al: The human corpus luteum: life cycle and
– Chorionic gonadotropin produced by placenta function in natural cycles. Fertil Steril. 92(3):1067-79, 2009
prevents regression of CL 13. Potter AW et al: US and CT evaluation of acute pelvic pain of
– Peaks in size at 7 weeks, then gradually degreases gynecologic origin in nonpregnant premenopausal patients.
Radiographics. 28(6):1645-59, 2008
in size as placenta begins to secrete hormones 14. Shwayder JM: Pelvic pain, adnexal masses, and ultrasound.
o CL that persists longer than 14 days may delay Semin Reprod Med. 26(3):252-65, 2008
menses/next ovarian cycle 15. Tamai K et al: MR features of physiologic and benign
conditions of the ovary. Eur Radiol. 16(12):2700-11, 2006
Treatment
• Typically, no follow-up or treatment is indicated
16. Swire MN et al: Various sonographic appearances of
the hemorrhagic corpus luteum cyst. Ultrasound Q.
o CLC is normal finding in women of childbearing age 20(2):45-58, 2004
o Follow-up ultrasound in 6 weeks (preferentially 17. Bennett GL et al: Gynecologic causes of acute pelvic pain:
immediately post menstruation) can be performed in spectrum of CT findings. Radiographics. 22(4):785-801,
equivocal cases 2002
• Combination estrogen-progesterone therapy for

18. Pretorius ES et al: Magnetic resonance imaging of the ovary.
Top Magn Reson Imaging. 12(2):131-46, 2001
persistent cysts
• No treatment for corpus luteum of pregnancy if
continuous reduction after 7 weeks
Consider
• CLC is most likely diagnosis when thick-walled
vascular cyst or solid-appearing mass is present in
premenopausal women
• "Ring of fire" appearance on Doppler US about
periphery of thick-walled irregular cyst
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a small left ovarian cyst
with a thickened enhancing
wall , consistent with a
corpus luteum cyst. In a
premenopausal patient, this
is a normal finding. Note the
uterine fundus . (Right)
Coronal CECT image in the
typical irregular, crenulated
appearance of the corpus
luteum cyst wall . As the
cyst collapses and involutes,
the corpus luteum may
simulate a solid enhancing
ovarian mass.

demonstrates a subtle,
solid-appearing ovarian
mass . Faint posterior
acoustic enhancement is
noted, a clue that this may
represent a hemorrhagic or
collapsed corpus luteum
cyst. (Right) Transvaginal
color Doppler ultrasound of
the ovary demonstrates the
solid-appearing mass to be
avascular with prominent
peripheral vascular flow
, the so-called ring
of fire appearance. In a
premenopausal patient, this
is consistent with a normal
corpus luteum.

demonstrates a slightly
hyperintense right ovarian
cyst with a thickened
irregular wall, an appearance
typical of an incidental corpus
luteum cyst. Note the simple-
appearing left ovarian follicular
cyst . (Right) Axial T1 C+ FS
thickened, irregular corpus
luteum wall . Note the
minimal, thin enhancement of
the follicular cyst wall .
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CORPUS LUTEAL CYST
Ovary
(Left) Transvaginal ultrasound of
the pelvis in a premenopausal
patient shows a thick-walled
cyst arising from the ovary, a
typical appearance of a corpus
luteum cyst. Note the increased
echogenicity of the irregular cyst
wall. (Right) Transvaginal color
Doppler ultrasound of the ovary
classic "ring of fire" appearance
of the corpus luteum, reflecting
the increased vascularity of the
cyst wall. Pulse wave Doppler
(not shown) demonstrated a low-
resistance waveform.
(Left) Coronal CECT image

demonstrates an incidental
enhancing cyst arising
from the right ovary. This is a
typical appearance of a corpus
luteum cyst, which is a common
normal finding in premenopausal
women. (Right) Axial CECT in
the classic irregular enhancing
wall of the corpus luteum
cyst. Cysts < 3 cm are normal
findings that require no further
follow-up imaging.

demonstrates a slightly T2
hyperintense right ovarian cyst
, consistent with a corpus
luteum cyst. Note the slightly
hypointense thickened cyst
wall. Small follicles are also seen
within the right ovary . (Right)
normal thickened enhancing
wall of the corpus luteum
cyst. As the cyst involutes and
the central cavity obliterates, the
corpus luteum may mimic a solid
enhancing ovarian mass.
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Ovary THECA LUTEIN CYSTS
Key Facts
Terminology • Cysts are thin walled
• Multiple theca lutein cysts in association with • No nodules or solid component
increased levels of, or abnormal ovarian response to, β- • "Spoke-wheel" appearance of ovaries: Central stroma
hCG surrounded by peripheral cysts

• Bilaterally enlarged ovaries with multiple cysts of • Ovarian epithelial neoplasms
varying size • Polycystic ovary syndrome (PCOS)
• Hypervascular central uterine mass if associated with • Ovarian hyperstimulation syndrome (OHSS)
molar pregnancy
• Ovaries are typically 6-12 cm in length but may be as Clinical Issues
large as 20 cm • Usually asymptomatic
• Individual cysts vary in size but usually measure several • Abdominal pain if hemorrhage, rupture, or torsion
centimeters occurs
• Preservation of underlying ovarian architecture • Typically regress after causative factor is removed
• "Multilocular" cysts is a misnomer, since individual • Conservative management recommended to avoid
cysts are separated by ovarian tissue rather than true unnecessary oophorectomy
septations
(Left) Graphic shows

enlargement of both ovaries
due to multiple theca lutein
cysts of varying size. (Right)
Axial transabdominal color
Doppler ultrasound in a
patient with hydatidiform
mole shows an enlarged
ovary (10 cm in length)
containing multiple simple-
appearing cysts. Normal
venous waveform is seen in
the intervening ovarian stroma.
The ovarian cysts completely
resolved on a follow-up
ultrasound performed 1 month
after evacuation of the molar
pregnancy.

an intrauterine pregnancy .
The placenta is heterogeneous
with multiple hyperintense
foci (cystic degeneration),
which proved to be a partial
mole. (Right) Coronal T2WI
bilateral ovarian enlargement
secondary to multiple
theca lutein cysts in a patient
with partial molar pregnancy.
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THECA LUTEIN CYSTS
Ovary
o No enhancement of cysts
TERMINOLOGY o Normal or increased enhancement of residual
Synonyms ovarian tissue between cysts mimics enhancing
• Hyperreactio luteinalis (HL) septations
▪ "Spoke-wheel" appearance
Definitions
• Multiple theca lutein cysts in association with Ultrasonographic Findings
increased levels of, or abnormal ovarian response to, • Grayscale ultrasound
human chorionic gonadotropin (β-hCG) o Bilaterally enlarged ovaries with multiple cysts giving
• Subtype of ovarian functional cysts along with appearance of multiloculated cystic masses
follicular cysts and corpus luteum cysts ▪ Cysts are typically anechoic
▪ Cysts may contain echoes if complicated by
hemorrhage
IMAGING ▪ Thin "septations" between cysts
General Features ▪ No wall irregularity or nodularity
o Uterus contains heterogeneous vascular mass in
• Best diagnostic clue sitting of gestational trophoblastic neoplasia (GTN)
o Bilaterally enlarged ovaries with multiple cysts of
varying size • Color Doppler
o Hypervascular central uterine mass if associated with o Normal Doppler flow or increased vascularity in
molar pregnancy surrounding ovarian parenchyma
• Location Imaging Recommendations
o Typically bilateral, rarely unilateral
• Size o Ultrasound is examination of choice for initial
o Ovaries are typically 6-12 cm in length but may be as diagnosis and follow-up
large as 20 cm ▪ Little incremental benefit to MR in diagnosis
o Individual cysts variable in size but usually measure
• Protocol advice
several cm o Combined use of transvaginal and transabdominal
• Morphology approach allows complete evaluation in setting of
o Preservation of underlying ovarian architecture large lesions
▪ "Multilocular" cysts is a misnomer since individual
cysts are separated by residual ovarian tissue rather
than true septations DIFFERENTIAL DIAGNOSIS
o Cysts are thin walled
Ovarian Epithelial Neoplasms
o No nodules or solid component
• • More frequently unilateral, although may be bilateral
Complications
o Cyst rupture or hemorrhage • Multilocular
o Ovarian torsion • Mural or septal thickening may be present
• Papillary projections or solid component
CT Findings • ADC in ovarian stroma in HL is significantly higher
• NECT than that in solid portions of ovarian cancers
o Multiple simple or less commonly high-attenuation
Luteoma of Pregnancy
• Ovarian enlargement (up to 12 cm)
ovarian cysts
• CECT
o "Spoke-wheel" appearance of ovaries: Central stroma • More commonly unilateral
surrounded by peripheral cysts • Solid or predominantly vascular solid mass
o Higher attenuation of stroma compared to cysts • Stromal cells are stimulated rather than follicles
MR Findings • May cause virilization
• T1WI • Most regress spontaneously
o Variable signal intensity of cysts Polycystic Ovary Syndrome (PCOS)
▪ Most often low signal intensity in keeping with • Multiple peripheral follicles
simple cysts
▪ May be intermediate to high signal intensity when
• Uniform size of cysts (usually ≤ 1 cm)
• Enlarged low signal intensity T2WI central stroma
• T2WI
hemorrhagic
• Clinical signs of hyperandrogenism and chronic
anovulation
o Cysts typically high signal intensity
▪ Signal intensity may vary between cysts due to Ovarian Hyperstimulation Syndrome (OHSS)
hemorrhage • Almost exclusively associated with ovulation induction
• DWI with gonadotropins or clomiphene citrate
o Rarely occurs in spontaneous pregnancy
o Intervening ovarian stroma exhibits hyperintensity
on DWI • Typically occurs in 1st trimester
o ADC in ovarian stroma in HL is significantly higher o HL, on the other hand, can occur any time during
than that in solid portions of ovarian cancers pregnancy
• T1WI C+ • OHSS may be associated with
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Ovary THECA LUTEIN CYSTS
o Ascites • In itself, presence of theca lutein cysts in GTN increases

o Pleural effusion risk of post-molar trophoblastic disease, especially if
o Hemoconcentration bilateral
o Oliguria
Treatment
• Conservative management recommended to avoid
PATHOLOGY unnecessary oophorectomy
General Features • Rare cases of torsion or hemorrhage may need
• Etiology
ovariotomy to remove infarcted tissue or to control
bleeding
o HL has unknown etiology
o ↑ production of β-hCG &/or ↑ ovarian sensitivity
to its prolonged exposure may be manifested as an DIAGNOSTIC CHECKLIST
exaggerated ovarian response → theca lutein cyst Consider
formation
▪ Most commonly due to GTN • Theca lutein cysts must be considered before ovarian
neoplasm in setting of a positive β-hCG or history of
▪ Multiple pregnancy
ovarian stimulation and bilateral "multilocular" ovarian
▪ Triploid gestation
•
cystic masses
Misdiagnosis can result in unnecessary surgical removal
o Presence of theca lutein cysts in GTN increases
of ovaries for suspected ovarian neoplasm
probability of one of its more aggressive forms:
Invasive mole or choriocarcinoma Image Interpretation Pearls
Gross Pathologic & Surgical Features • Association of molar pregnancy and enlarged
• Markedly edematous and congested ovarian
multicystic ovaries is diagnostic of theca lutein cysts
parenchyma
• Multiple cysts of varying size with preservation of
• Numerous unilocular cysts
underlying ovarian architecture
• Cysts contain amber-colored serosanguineous fluid SELECTED REFERENCES

• Diagnosis seldom confirmed histologically due to
1. Yacobozzi M et al: Adnexal masses in pregnancy. Semin
Ultrasound CT MR. 33(1):55-64, 2012
benign evolution of disease in most cases 2. Takeuchi M et al: Magnetic resonance manifestations
• Numerous luteinized follicular cysts of hyperreactio luteinalis. J Comput Assist Tomogr.
• Marked luteinization of theca interna cells and, in some 35(3):343-6, 2011
cases, granulosa cells
• Marked edema of theca interna layer organs on MR images: changes induced by various
• Intervening stroma containing luteinized stromal cells

4. Allen SD et al: Radiology of gestational trophoblastic
neoplasia. Clin Radiol. 61(4):301-13, 2006
5. Tamai K et al: MR features of physiologic and benign
CLINICAL ISSUES conditions of the ovary. Eur Radiol. 16(12):2700-11, 2006
6. Jung SE et al: MR imaging of maternal diseases in pregnancy.
Presentation
7. al-Harbi O et al: Recurrent bilateral theca lutein cysts in
o Usually asymptomatic association with normal pregnancy. Ultrasound Obstet
o Abdominal pain if hemorrhage, rupture, or torsion Gynecol. 11(3):222-4, 1998
occurs 8. Wagner BJ et al: From the archives of the AFIP. Gestational
• Other signs/symptoms trophoblastic disease: radiologic-pathologic correlation.
Radiographics. 16(1):131-48, 1996
o Virilization secondary to androgen production in
9. Montz FJ et al: The natural history of theca lutein cysts.
15-25% of cases unassociated with GTN Obstet Gynecol. 72(2):247-51, 1988
▪ Serum testosterone elevated in virilized as well as 10. Hricak H et al: Gestational trophoblastic neoplasm of the
nonvirilized patients uterus: MR assessment. Radiology. 161(1):11-6, 1986
Demographics
• Age
o Women of childbearing age
• Epidemiology
o 25-45% of women with GTN will have theca lutein
cysts
• Excellent
• Typically regresses after causative factor is removed
o When associated with GTN, disappears within 2-4
months after resolution of condition
o Rare cases of persistence or increase in size after β-
5 HCG regression
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THECA LUTEIN CYSTS
Ovary
old woman with very high levels
of β-hCG shows an enlarged
uterus with an expanded
cavity filled with heterogeneous
predominantly hypoattenuating
tissue. (Right) Axial CECT in the
enlarged ovaries composed
of multiple cysts of different sizes
separated by enhancing thin
septa. Note also the expanded
uterine cavity with fine
enhancing septa .

with emesis and was found
to have a positive pregnancy
test shows enlarged uterus
with distended uterine cavity
. (Right) Axial CECT in the
enlarged ovaries composed
of multiple cysts of different sizes
separated by thin septa. The
uterine contents were evacuated
and were found to be a complete
hydatidiform mole.

woman with a diagnosis of GTN
shows an enlarged ovary
composed of numerous different-
sized simple cysts. These are
individual cysts separated by
residual ovarian tissue rather
than true septations, as seen in
ovarian epithelial neoplasms.
(Right) Sagittal transvaginal
pregnant woman with twin
gestation shows an enlarged
ovary composed of numerous
different-sized simple cysts
separated by thin septations.
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Ovary HEMORRHAGIC OVARIAN CYST
Key Facts
• Functional (usually corpus luteum) cyst with internal • Endometrioma
hemorrhage o Consider if lesion is unchanged on follow-up exams
Imaging • Ectopic pregnancy
o Most occur in fallopian tube and can be separated
• Specific US appearance in 90% of cases from ovary by gentle pressure with transducer
o Fibrin strands create reticular pattern described as
lace-like, fishnet, or cobweb appearance
• Dermoid cyst
o Echogenic retracting clot of fluid-fluid level Clinical Issues
o Avascular cyst contents on color Doppler
o Cyst wall is often prominent with increased flow
• May be incidental finding or present with acute pelvic
pain
o Echogenic free fluid (hemoperitoneum) may be seen
with cyst rupture
• Most resolve or significantly decrease in size within 8
weeks
• Classic teaching is high signal intensity on both T1WI • No follow-up necessary if classic appearance and ≤ 5
and T2WI but actually highly variable cm
o Variability is dependent on multiple factors
including concentration and age of blood products
• If > 5 cm, short-term follow-up (6-12 weeks)
recommended
(Left) With ovulation, the

surface epithelium ruptures
as the egg is extruded and a
corpus luteal cyst forms. This
is the most common time for
hemorrhage to occur. (Right) A
cut section of an ovary shows
hemorrhage within a corpus
luteal cyst. Note the thick
wall , which is often quite
vascular on color Doppler
ultrasound.
(Left) Transvaginal color

Doppler shows a hemorrhagic
cyst with a fine reticular
meshwork of fibrin strands
and a straight edge along the
retracting clot . (Right)
Transvaginal ultrasound
in a different case shows
somewhat thicker septations
with a cobweb appearance of
the clot. Despite the classic
appearance, always use color
Doppler to rule out any flow,
as would be seen in a cystic
neoplasm.
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HEMORRHAGIC OVARIAN CYST
Ovary
TERMINOLOGY ▪ Typically not as hyperintense as seen with
endometriomas
Definitions • T2WI
• Functional (usually corpus luteum) cyst with internal o 23% hyperintense
hemorrhage o 73% heterogeneous with hyperintense area
o 6% no hyperintense area
o Loss of signal on T2WI (shading) has been reported
IMAGING ▪ Not as specific to endometriomas as once thought
General Features o No dark spot sign
• Best diagnostic clue Imaging Recommendations
o Cyst with internal reticular pattern of echoes and no
internal flow
o Endovaginal US with color Doppler
o Shows significant clot retraction and cyst involution
▪ Ensure no solid elements
in 6-8 weeks
• Size
o Typically < 5 cm but can be quite large (> 10 cm) DIFFERENTIAL DIAGNOSIS
Ultrasonographic Findings Endometrioma
• Specific US appearance in 90% of cases • Extrauterine functional endometrial tissue involving
• Complex cystic ovarian mass ovary
o Results in thick concentrated blood products
o Fibrin strands create reticular pattern described as
lace-like, fishnet, or cobweb appearance ("chocolate cyst")
o Echogenic retracting clot with convex, concave, or o Bilateral in 15-20% of cases
o Presents with chronic cyclic pain or infertility
straight margin
o Fluid-fluid level • Ultrasound
o Diffuse low-level echoes are less specific o Diffuse low-level echoes (ground-glass appearance)
▪ Appearance overlaps with endometrioma with hyperechoic foci in cyst wall
o May be isoechoic to ovarian tissue, giving solid o Does not change on follow-up scans
appearance • T1WI
▪ Look for posterior enhanced through transmission o Single or multiple homogeneous high-signal masses
to differentiate from solid lesion • T2WI
• Cysts are intraovarian or exophytic o T2 shading: Loss of signal ranging from faint to
o Look for claw sign (ovarian tissue partially around complete signal void
cyst) ▪ Newer studies suggest not as specific as once
o Cannot separate from ovary with transducer pressure thought (45-83%)
▪ Helps differentiate from ectopic pregnancy o Dark spot sign felt to be highly specific
• Avascular cyst contents on color Doppler ▪ Discrete markedly hypointense foci within cyst or
o Cyst wall often prominent with increased flow adjacent to wall but not within wall itself
• Echogenic free fluid (hemoperitoneum) may be seen Ectopic Pregnancy
with cyst rupture
o Always scan in cul-de-sac to evaluate for free fluid • Positive β-HCG
o If significant, also scan by right kidney (Morrison • Most occur in fallopian tube and can be separated from
ovary by gentle pressure with transducer
pouch) to look for upper abdominal extension
CT Findings Dermoid Cyst
• NECT • Dermoid mesh due to linear intersecting strands of hair
can simulate lace-like appearance but multiple other
o Adnexal cyst containing high-attenuation fluid
findings are usually present
▪ Typically > 30 HU o Echogenic mural nodule (Rokitansky nodule)
o May have associated hemoperitoneum o Calcifications; may be extensive
▪ Typically > 25 HU o Fat-fluid levels
MR Findings • Bilateral in 10-15% of cases
• Classic teaching is high signal intensity on both T1WI • Does not present with acute pain unless torsion or
and T2WI but actually highly variable rupture
• Variability dependent on multiple factors Ovarian Torsion
o Quantity of blood
o Hematocrit • Enlarged echogenic ovary with prominent peripheral
follicles
o Protein concentration
o Form of hemoglobin • Whirlpool (twisted pedicle) sign
o Clot formation/retraction • Normal to decreased vascularity of adnexa
o Venous flow first affected
• T1WI
o Absent arterial flow with infarcted ovary
o 64% hypointense
o 36% intermediate or high signal • May have hemorrhagic cyst and torsion
o Cyst serves as lead point for torsion
▪ Hyperintensity is better seen on T1FS images
• Patients have severe pain, often with vomiting 5
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Tubo-Ovarian Abscess – Any size: 6-12 week follow-up to ensure

• Often multiple complex masses involving fallopian resolution
▪ Late post menopause
tube, ovary, and peritoneal spaces
• Associated with dilated fallopian tube with low-level – Consider surgical evaluation
echoes (pyosalpinx) • Rupture with hemoperitoneum does not
• Perihepatic inflammatory changes (Fitz-Hugh-Curtis generally require treatment as long as patient is
hemodynamically stable
syndrome)
• Patients have fever and white count in addition to o May rarely require surgery if patient becomes
hemodynamically unstable
pelvic pain
Ovarian Cancer
• Complex cystic mass containing mural nodules &/or DIAGNOSTIC CHECKLIST
thick septa with color Doppler flow Consider
• Does not usually present with acute pain • Consider endometrioma if lesion is unchanged on
follow-up exams
PATHOLOGY Image Interpretation Pearls
General Features • Classic appearance
• Etiology o Reticular strands of fibrin
o Retracting echogenic clot
o Hemorrhage generally occurs during ovulation
o Avascular on color Doppler sonography
secondary to rupture of germinal epithelium
▪ Most hemorrhagic cysts are, therefore, corpus
luteal cysts SELECTED REFERENCES
1. Corwin MT et al: Differentiation of ovarian endometriomas
o Rupture with hemoperitoneum
from hemorrhagic cysts at MR imaging: utility of the T2 dark
o Large cysts may serve as lead point for ovarian torsion spot sign. Radiology. 271(1):126-32, 2014
2. Valentin L et al: Risk of malignancy in unilocular cysts: a
• Thin or thick-walled cyst with clot &/or
study of 1148 adnexal masses classified as unilocular cysts
at transvaginal ultrasound and review of the literature.
serosanguineous fluid Ultrasound Obstet Gynecol. 41(1):80-9, 2013
3. Patel MD: Pitfalls in the sonographic evaluation of adnexal
• Benign epithelial cyst with internal hemorrhage
masses. Ultrasound Q. 28(1):29-40, 2012
4. Ding Z et al: Sonographic value in diagnosis of hemorrhagic
ovarian cysts. Eur J Gynaecol Oncol. 31(1):87-9, 2010
CLINICAL ISSUES other adnexal cysts imaged at US: Society of Radiologists in
Ultrasound Consensus Conference Statement. Radiology.
Presentation
256(3):943-54, 2010
6. Vandermeer FQ et al: Imaging of acute pelvic pain. Clin
o Acute pelvic pain Obstet Gynecol. 52(1):2-20, 2009
o Often asymptomatic 7. Kamaya A et al: Emergency gynecologic imaging. Semin
▪ Palpable adnexal mass Ultrasound CT MR. 2008 Oct;29(5):353-68. Review. Erratum
▪ Incidental finding on scan being done for other in: Semin Ultrasound CT MR. 29(6):491, 2008
8. Kanso HN et al: Variable MR findings in ovarian functional
indications
hemorrhagic cysts. J Magn Reson Imaging. 24(2):356-61,
Demographics 2006
• Premenopausal women 9. Patel MD et al: The likelihood ratio of sonographic findings
for the diagnosis of hemorrhagic ovarian cysts. J Ultrasound
o May occasionally see in early postmenopausal
Med. 24(5):607-14; quiz 615, 2005
women 10. Swire MN et al: Various sonographic appearances of
• Late postmenopausal women should not ovulate; the hemorrhagic corpus luteum cyst. Ultrasound Q.
therefore, any hemorrhagic-appearing cystic lesion 20(2):45-58, 2004
should be considered malignant 11. Jain KA: Sonographic spectrum of hemorrhagic ovarian
cysts. J Ultrasound Med. 21(8):879-86, 2002
• Most resolve or significantly decrease in size within 8
weeks
Treatment
• Society of Radiologists in Ultrasound guidelines for
follow-up
o Reproductive age
▪ No follow-up necessary if classic appearance and ≤
5 cm
▪ If > 5 cm, short-term follow-up (6-12 weeks)
– Ideally, this should be done in follicular phase,
5 days 3-10 of menstrual cycle

▪ Early post menopause
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Ovary
(Left) Transvaginal color Doppler
shows a fishnet appearance,
another common appearance
of a hemorrhagic cyst. (Right)
Transvaginal color Doppler
ultrasound shows a hemorrhagic
corpus luteal cyst in a pregnant
woman with pelvic pain. It is
filled with low-level echoes
and has significant flow
within the wall of the cyst
but no flow internally. This can
be confused with an ectopic
pregnancy but most ectopics are
located in the fallopian tube and
can be separated from the ovary
by exerting gentle pressure with
the probe.
(Left) T1WI MR shows an

intermediate to slightly high
signal intensity right ovarian
cystic mass . (Right) T1WI FS
should always be performed as
it increases lesion conspicuity
and rules out a fat-containing
lesion. Hemorrhagic cysts are
quite variable in signal intensity
reflecting both the age and
concentration of blood products.
(Left) T2WI MR in the same

patient shows that the lesion
remains high signal. (Right)
Transvaginal ultrasound in the
same patient shows low-level
echoes with a slight reticular
pattern typical of a hemorrhagic
cyst . Note the posterior
acoustic enhancement . In
the reproductive age group,
hemorrhagic cysts with a classic
appearance do not require
follow-up unless > 5 cm.
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(Left) Color Doppler

ultrasound shows a classic
fishnet appearance created
by fibrinous strands . In
addition, there is a retracting
clot adherent to the cyst
wall. (Right) Transvaginal
ultrasound shows another
typical case of a hemorrhagic
cyst with fibrinous strands
and a retracting clot .

a predominately hypointense
left ovarian cyst, with vague
hyperintense fluid-fluid
level posteriorly . While
the classic teaching is that
hemorrhagic cysts are
hyperintense on T1WI, they
are actually quite variable,
with many being hypointense,
the result of a small amount
of hemorrhage in a relatively
larger amount of fluid within
the cyst. (Right) Axial T1WI
C+ shows enhancement of
the thin surrounding cyst wall
, but no enhancement of
internal components.

the same case best shows
the fluid-fluid level with a
separation of the clot from
the larger serous component.
ultrasound in the same case
shows the smooth edge of the
retracting clot .
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Ovary
a high signal intensity cyst with
a lobular area of low signal
intensity , representing an
area of forming clot. (Right) Axial
T2WI MR shows the low-signal
clot to better advantage.
This is another appearance of
hemorrhage on MR. A follow-up
ultrasound was performed in this
case. The clot had retracted with
near complete involution of the
cyst by 6 weeks.

shows an incomplete margin
of the right ovary in this woman
who was in the emergency room
with pelvic pain. Note the mildly
echogenic surrounding free fluid
. (Right) A sagittal transvaginal
image of the cul-de-sac in the
same patient shows fluid that is
more echogenic , the result
of clot formation. Rupture of a
hemorrhagic cyst can cause a
hemoperitoneum. It is always
important to look for echogenic
free fluid in the cul-de-sac and
in Morrison pouch in the right
upper quadrant.

ruptured hemorrhagic corpus
luteal cyst (48 HU) with
surrounding high-attenuation
free fluid (hemoperitoneum).
(Right) Axial CECT, in a
different case, shows a ruptured
hemorrhagic cyst (note indistinct
border ) with a very large
hemoperitoneum . Even when
large, a hemoperitoneum from
a ruptured cyst does not usually
require surgery unless the patient
is hemodynamically unstable.
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Ovary OVARIAN INCLUSION CYST
Key Facts
• Invagination of ovarian cortical surface after • Developing ovarian follicle
ovulation, resulting in subsequent cyst formation • Follicular cyst
Imaging • Serous cystadenoma
• Small, simple-appearing ovarian cyst most commonly • Paraovarian/paratubal cyst
seen in postmenopausal women Clinical Issues
o Unilocular
o Thin, smooth wall • Asymptomatic
• < 10 mm in size • Common incidental finding with no clinical
•
significance
Imaging features suggest simple cyst
o CT: Well-marginated fluid-density ovarian lesion • Typically remain stable over time or involute
without contrast enhancement • Simple ovarian cysts measuring ≤ 1 cm require no
o MR: Nonenhancing homogeneously T1 hypointense follow-up in pre- or postmenopausal patients
and T2 hyperintense ovarian lesion • Similar etiology and pathological features as benign
o US: Anechoic well-marginated cyst with posterior ovarian serous cystadenoma
o Differentiation between the two is by arbitrary size
acoustic enhancement and no internal flow upon
cut-off of 10 mm
Doppler US imaging
(Left) Sagittal T2WI FS

MR demonstrates a small
homogeneous rounded
hyperintense cyst within
the left ovary. (Right) Axial
T1WI C+ FS MR from the
cyst to be hypointense
and nonenhancing. In this
postmenopausal patient, this
is most likely to represent an
ovarian inclusion cyst.

small incidental rounded
hypodense lesion
within the atrophic right
ovary. (Right) Longitudinal
same patient shows a small
simple cyst arising from
the right ovary . When
compared to prior studies,
this had been unchanged for
several years and was most
consistent with an ovarian
inclusion cyst.
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OVARIAN INCLUSION CYST
Ovary
o No enhancement of cyst contents
TERMINOLOGY
▪ Cyst is hypointense relative to surrounding ovarian
Abbreviations cortex and stroma
• Ovarian inclusion cyst (OIC) o Discrete enhancement of thin cyst wall
o There should not be enhancing mural nodularity or
Synonyms irregular septations
• Epithelial inclusion cyst
• Cortical inclusion cyst Ultrasonographic Findings
• Germinal inclusion cyst • Grayscale ultrasound
o Sonographic features identical to ovarian follicles
• Ovarian epithelial inclusions o Simple-appearing cyst < 10 mm in size
Definitions ▪ Anechoic thin-walled cyst
• Invagination of ovarian cortical surface epithelium ▪ Posterior acoustic enhancement
with loss of communication with ovarian surface and ▪ Well-defined back wall
subsequent cyst formation o Punctate echogenic foci may be seen at periphery of
ovaries
▪ Represent psammoma bodies associated with
IMAGING inclusion cysts
General Features • Color Doppler
• Best diagnostic clue o No internal flow
o No significant peripheral flow
o Simple-appearing ovarian cyst most commonly
arising in postmenopausal woman Imaging Recommendations
• Location • Best imaging tool
o Arises from superficial ovarian cortex o Transvaginal ultrasound (TVUS) is accurate for
o Typically located immediately beneath capsule or detection and characterization
within 1-2 mm of outer surface o MR can be helpful as problem-solving modality
• Size • Protocol advice
o Small, < 10 mm in size o Adjust focal zones and gain on TVUS to demonstrate
▪ 10 mm is arbitrary cut-off in size between OIC and simple nature of cyst
benign ovarian serous cystadenomas
• Morphology
o Usually unilocular
▪ Seldom multilocular Developing Ovarian Follicle
o Round or ovoid
o Thin, smooth wall • Imaging appearance identical to inclusion cyst
o Fluid contents simple • Not rare during menopause
o Signs of complication are rare and typically absent o Statistically, inclusion cyst is far more frequent than
▪ Complicated cysts in postmenopausal patients ovarian follicle at this age
require further evaluation/follow-up • Most are atretic cystic follicles
CT Findings Follicular Cyst

• CECT • Imaging appearance identical to inclusion cyst
o Hypodense round or oval-shaped lesion arising from • More common during reproductive age and early
ovary menopause
o Density of simple fluid (0-10 HU), though small size • More likely to exhibit signs of complication
and volume averaging may artifactually increase (hemorrhage, wall irregularity)
density • Will spontaneously regress over time
o Up to 10 mm in size
Serous Cystadenoma
• CT can suggest presence of inclusion cyst but is not
• Simple ovarian cyst > 10 mm in size
•
diagnostic
• Unilocular
• Complex lesions with irregular septations, papillary
Often difficult to visualize and confidently characterize
on CT
projections, &/or mural nodules suggest malignancy
MR Findings
• T1WI Paraovarian/Paratubal Cyst
• Thin-walled, oblong adnexal cyst
o Typical features of simple cyst
▪ Low signal intensity (SI) lesion • Ovary identified as separate structure
▪ SI lower than ovarian stroma • Multilocular or unilocular
• T2WI
o Typical features of simple cyst PATHOLOGY
▪ High SI fluid contents
▪ Thin wall with lower SI than ovarian stroma General Features
▪ < 10 mm in size • Etiology
• T1WI C+
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o Sequela of ovulation with subsequent invagination of Treatment

ovarian surface epithelium/mesothelium • None needed for epithelial inclusion cysts
• Guidelines for management of simple unilocular cysts
o Patients with unilateral ovarian carcinoma have in postmenopausal patients
increased number of surface epithelial inclusion cysts o Cysts measuring ≤ 1 cm require no follow-up
in contralateral ovary o Cysts between 1 cm and 7 cm require yearly follow-
• Pathophysiology up
o After ovulation, surface epithelium is believed to o Cysts > 7 cm require MR imaging or surgical
cover resultant defect as part of a reparative process evaluation
o Invagination of surface epithelium is frequent • Guidelines for management of simple unilocular cysts
occurrence in reproductive age patients
o Entrapment of surface mesothelial cells within o Cysts measuring ≤ 5 cm require no follow-up
stroma is responsible for inclusion cysts o Cysts between 5 cm and 7 cm require yearly follow-
• Ovulation is most common cited etiology, although up
some evidence suggests ovulation may not be the only o Cysts > 7 cm require MR imaging or surgical
cause of inclusion cysts evaluation
o Can increase in number after menopause
o In some studies, more numerous in multiparous than
nulliparous women DIAGNOSTIC CHECKLIST
o Can be seen in patients with polycystic ovary
Consider
syndrome (PCOS)
o Other theories include • Consider epithelial inclusion cyst in postmenopausal
woman with simple ovarian cyst < 10 mm
▪ Entrapment of surface mesothelial cells by
adhesions Image Interpretation Pearls
▪ Simple surface infolding • Small, simple ovarian cyst mimicking a follicle
• Clear cyst on superficial cortex of ovary SELECTED REFERENCES
Microscopic Features 1. Laing FC et al: US of the ovary and adnexa: to worry or not
• Cyst surrounded by ovarian stroma to worry? Radiographics. 32(6):1621-39; discussion 1640-2,
• Lined by single layer of columnar epithelium, ciliated

2012
2. Mohaghegh P et al: Imaging strategy for early ovarian
or nonciliated serous cuboidal epithelium, or flat cancer: characterization of adnexal masses with
epithelium conventional and advanced imaging techniques.
• Psammomatous calcifications may be seen within Radiographics. 32(6):1751-73, 2012
lumen of epithelial inclusion cysts
• By definition, an inclusion cyst measuring > 10 mm is other adnexal cysts imaged at US: Society of Radiologists in
Ultrasound Consensus Conference Statement. Radiology.
termed a benign serous cystadenoma 256(3):943-54, 2010
CLINICAL ISSUES organs on MR images: changes induced by various
Presentation 5. Dubeau L: The cell of origin of ovarian epithelial tumours.
• Most common signs/symptoms Lancet Oncol. 9(12):1191-7, 2008
6. Dikensoy E et al: Serum CA-125 is a good predictor of benign
o Asymptomatic disease in patients with postmenopausal ovarian cysts. Eur J
Gynaecol Oncol. 28(1):45-7, 2007
Demographics
• Age
7. McDonald JM et al: The incidental postmenopausal adnexal
mass. Clin Obstet Gynecol. 49(3):506-16, 2006
o Very common in postmenopausal women 8. Dørum A et al: Prevalence and histologic diagnosis of
o Can be seen in females of all ages including fetuses, adnexal cysts in postmenopausal women: an autopsy study.
infants, and adolescents Am J Obstet Gynecol. 192(1):48-54, 2005
9. Heller DS et al: Are germinal inclusion cysts markers of
Natural History & Prognosis ovulation? Gynecol Oncol. 96(2):496-9, 2005
• Typically remain stable over time or involute 10. Jung SE et al: CT and MR imaging of ovarian tumors
• Simple adnexal cysts < 10 cm are likely to be benign with emphasis on differential diagnosis. Radiographics.
o < 1% risk of malignancy in patient of any age 22(6):1305-25, 2002
•
11. Feeley KM et al: Precursor lesions of ovarian epithelial
Theorized to be a site of origin of ovarian carcinoma, malignancy. Histopathology. 38(2):87-95, 2001
although OIC are so prevalent that cannot be 12. Kupfer MC et al: Transvaginal sonographic evaluation of
considered a premalignant lesion multiple peripherally distributed echogenic foci of the
o Presence of OIC has no significance in identifying ovary: prevalence and histologic correlation. AJR Am J
patients at increased risk of ovarian malignancy Roentgenol. 171(2):483-6, 1998
o Local environmental and hormonal influences may
initiate cellular changes to cyst epithelium that result
in metaplasia and subsequent neoplasia
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Ovary
postmenopausal patient
shows a small well-marginated
hypodensity within the left
ovary, which has an atrophic
appearance. Note the adjacent
uterus and the round
ligament . (Right) Transverse
rounded anechoic simple cyst
arising from the left ovary .
This is most likely to represent an

an atrophic appearance of
the left ovary , which
contains a small, rounded, well-
marginated hypodensity .
In a postmenopausal patient,
this is likely to represent an
ovarian inclusion cyst. (Right)
ultrasound in a different patient
shows a hypoechoic cystic
lesion (calipers) arising from
the left ovary. Linear artifact
extending through the
lesion prevents accurate
characterization.

demonstrates the left ovarian
lesion (calipers) to be simple
in appearance and likely to
represent an ovarian inclusion
cyst. (Right) Transverse power
same patient demonstrates no
internal flow within the cyst. A
small simple ovarian cyst in a
postmenopausal patient is likely
to represent an ovarian inclusion
cyst.
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postmenopausal patient
shows a bilobed right ovarian
cystic lesion . (Right)
patient shows the bilobed right
ovarian cystic lesion to be
homogeneously hypointense.

the cystic lesion to have a
thin central hypointense
band , consistent with 2
adjacent cysts. There was no
significant interval change on
serial follow-up; these findings
were most consistent with
paired epithelial inclusion
cysts. (Right) Longitudinal
a simple-appearing cyst
arising from the left ovary .

solitary left ovarian rounded
hypointense lesion ,
corresponding to the cyst.
hyperintense, most suggestive
of an ovarian inclusion cyst in
this postmenopausal patient.
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Ovary
(Left) Axial CECT in an
asymptomatic postmenopausal
patient demonstrates a small
rounded hypodensity within
the atrophic right ovary .
shows a rounded anechoic
simple cyst within the right
ovary , consistent with
an inclusion cyst. Note the
peripheral location of the cyst
with the ovarian parenchyma.

ultrasound shows a small, ovoid,
simple-appearing left ovarian
cyst in this postmenopausal
patient. The patient was
asymptomatic. (Right) Axial
T2WI FS MR in the same patient
shows the left ovarian cyst to
be homogeneously hyperintense.

hypointense and without
enhancing mural nodularity or
septation. (Right) Longitudinal
transvaginal ultrasound in
a different patient shows a
small simple cyst arising
from the right ovary . In
postmenopausal patients, a small
simple cyst that remains stable in
size and imaging appearance on
follow-up is likely to represent an
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Ovary OVARIAN CARCINOMA OVERVIEW

(T) Primary Tumor
T1 I Tumor limited to ovaries (1 or both)
T1a IA Tumor limited to 1 ovary; capsule intact, no tumor on ovarian surface; no malignant cells
in ascites or peritoneal washing
T1b IB Tumor limited to both ovaries; capsules intact, no tumor on ovarian surface; no malignant
cells in ascites or peritoneal washings
T1c IC Tumor limited to 1 or both ovaries with any of the following: Capsule ruptured, tumor on
ovarian surface, malignant cells in ascites or peritoneal washings
T2 II Tumor involves 1 or both ovaries with pelvic extension
T2a IIA Extension &/or implants on uterus &/or tube(s); no malignant cells in ascites or peritoneal
washings
T2b IIB Extension to &/or implants on other pelvic tissues; no malignant cells in ascites or
peritoneal washings
T2c IIC Pelvic extension &/or implants with malignant cells in ascites or peritoneal washings
T3 III Tumor involves 1 or both ovaries with peritoneal metastasis outside pelvis
T3a IIIA Microscopic peritoneal metastasis beyond pelvis (no macroscopic tumor)
T3b IIIB Macroscopic peritoneal metastasis beyond pelvis ≤ 2 cm in greatest dimension
T3c IIIC Peritoneal metastasis beyond pelvis > 2 cm in greatest dimension &/or regional lymph
node metastasis

N1 IIIC Regional lymph node metastasis

M1 IV Distant metastasis (excludes peritoneal metastasis)

Stage T N M
I T1 N0 M0
IA T1a N0 M0
IB T1b N0 M0
IC T1c N0 M0
II T2 N0 M0
IIA T2a N0 M0
IIB T2b N0 M0
IIC T2c N0 M0
III T3 N0 M0
IIIA T3a N0 M0
IIIB T3b N0 M0
IIIC T3c N0 M0
Any T N1 M0
IV Any T Any N M1
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OVARIAN CARCINOMA OVERVIEW
Ovary
T1a (FIGO IA) T1a (FIGO IA)
Low-power magnification of H&E shows ovarian carcinoma that is High-power magnification shows sheets of serous carcinoma cells
limited to 1 ovary with intact capsule (T1a). Sheets of tumor cells and an intact capsule overlying ovarian stroma.
are seen with intact capsule .
T1c (FIGO IC) T1c (FIGO IC)
Low-power magnification shows ovarian tumor extending through Higher magnification shows a close-up of the cords and nests of
the capsule to the ovarian surface (T1c). The H&E stain shows tumor cells and ovarian plump spindle stromal cells .
ovarian tumor extending to the ovarian surface . Note normal
ovarian tissue on the right side of the photomicrograph.
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T2a (FIGO IIA) T2b (FIGO IIB)
Low-power magnification of H&E stain shows a cross section of a Low-power magnification of H&E stain shows an implanted ovarian
fallopian tube with ovarian tumor nodule implanted on the nodule to the serosal surface of the rectosigmoid colon (T2b). The
serosal aspect. The inset shows a high-magnification view of the mucosal side of the rectosigmoid is highlighted , as well as the
neoplastic malignant cells of the nodule. tumor nodule .
T3 (FIGO III) T3c (FIGO IIIC)
H&E section shows peritoneal metastasis of ovarian papillary serous Low-power magnification of H&E stain shows a metastatic ovarian
carcinoma outside the pelvis (T3). The nodule in the upper part of carcinoma to a regional lymph node (T3c). The lymph node
the slide represents the metastatic tumor and is implanted in the capsule is highlighted ; tumor nest is present within the
fibro-fatty tissue of the peritoneum (lower aspect of the slide). lymph node.
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Ovary
T1a (FIGO IA) T1b (FIGO IB)
T1a tumors are limited to 1 ovary with intact capsule, no tumor on T1b tumors are limited to both ovaries with intact capsules, no
the ovarian surface, and no malignant cells in ascites or peritoneal tumor on the ovarian surface, and no malignant cells in ascites or
washings. peritoneal washings.
T1c (FIGO IC) T2a (FIGO IIA)
T1c tumors are limited to 1 or both ovaries with capsule rupture, T2a tumors involve 1 or both ovaries with pelvic extension to the
tumor on the ovarian surface , or malignant cells in ascites or uterus or fallopian tube. No malignant cells are found in ascites or
peritoneal washings. peritoneal washings.
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T2b (FIGO IIB) T2c (FIGO IIC)
T2b tumors involve 1 or both ovaries with pelvic extension &/or T2c tumors involve 1 or both ovaries with pelvic extension &/or
implants to other pelvic organs. No malignant cells in ascites or implants, with malignant cells in ascites or peritoneal washings.
peritoneal washings are found.
T3a (FIGO IIIA) T3b (FIGO IIIB)
T3a tumors involve microscopic peritoneal metastases beyond the T3b tumors feature macroscopic peritoneal metastases beyond the
pelvis. This cannot be visualized by imaging; rather, it is found pelvis that are ≤ 2 cm in greatest dimension.
through peritoneal biopsy at staging laparotomy.
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Ovary
T3c (FIGO IIIC) Nodal Drainage of the Ovary
T3c tumors involve macroscopic peritoneal metastases beyond the The main ovarian lymphatics follow the ovarian veins to the
pelvis > 2 cm in greatest dimension. paraaortic lymph nodes . Lymphatic spread may also occur
through the broad ligament to the pelvic lymph nodes and
along the round ligament to the inguinal lymph nodes .

Liver 45-48%
Lung 34-39%
Pleura 25%
Adrenal gland 15-21%
Spleen 15-20%
Bone 11%
Kidney 7-10%
Skin and subcutaneous 5%
tissue
Brain 3-6%
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o Malignant cells shedding from tumor surface into
OVERVIEW peritoneal cavity
o Malignant cells are distributed by gravity into cul-
Classification
de-sac or follow normal routes of peritoneal fluid
• Primary ovarian carcinomas are differentiated by cell circulation
origin
o Epithelial ovarian tumors (EOT): 90% of ovarian ▪ Preferential flow and seeding along right paracolic
gutter, liver capsule, and right hemidiaphragm
carcinomas o Peritoneal fluid normally drains through rich
▪ Serous cystadenocarcinoma (60%)
lymphatic capillary network of diaphragm to
▪ Endometrioid carcinoma (10%)
supradiaphragmatic lymph nodes
▪ Clear cell carcinoma (10%)
▪ Occlusion of these lymphatics by tumor cells
▪ Carcinosarcoma (10%)
blocks absorption of peritoneal fluid
▪ Mixed (5%)
▪ Contributes to accumulation of malignant ascites
▪ Mucinous cystadenocarcinoma (3%) o Most common sites of peritoneal metastases
– Less common than initially thought
▪ Cul-de-sac
– Many mucinous tumors of ovaries are actually
▪ Greater omentum
metastatic from gastrointestinal primary
▪ Paracolic gutters
▪ Undifferentiated carcinoma (1%)
▪ Small and large bowel serosal surface
▪ Malignant Brenner tumor (< 1%)
o Nonepithelial ovarian tumors: 10% of ovarian ▪ Liver surface
▪ Subphrenic spaces
carcinomas o Other potential sites of metastases
▪ Germ cell tumors
▪ Porta hepatis
– Dysgerminoma
▪ Fissure for ligamentum teres
– Embryonal carcinoma
▪ Lesser sac
– Immature teratoma
▪ Gastrosplenic and gastrohepatic ligaments
– Polyembryoma
▪ Splenic hilum
– Choriocarcinoma o Primary peritoneal carcinoma
– Mixed germ cell tumors
▪ Unusual tumor of similar histiogenic origin to
▪ Sex cord-stromal tumors
primary ovarian carcinoma
– Malignant granulosa cell tumor
▪ Primary tumor of peritoneum that diffusely
• Nonepithelial primary ovarian cancers may be staged involves peritoneal surface but spares or only
using TNM classification system
superficially involves ovaries
• Primary peritoneal carcinoma is included with ovarian ▪ Generally diagnosed in state of peritoneal
carcinoma in 7th edition AJCC Cancer Staging Manual
carcinomatosis
▪ Poor prognosis
▪ Biopsy important to differentiate primary
PATHOLOGY peritoneal carcinoma from peritoneal
Routes of Spread carcinomatosis (due to other cancers,
mesothelioma, lymphomatosis, or tuberculous
• Understanding pattern of spread is crucial for adequate peritonitis)
radiological and surgical staging o Pseudomyxoma peritonei
• Local spread ▪ Growing body of immunohistochemical and
o Direct extension to surrounding pelvic structures
molecular genetic studies suggest that majority are
▪ Commonly fallopian tubes, uterus, and
actually secondary to appendiceal tumors in both
contralateral adnexa
men and women
▪ Less commonly rectum, bladder, and pelvic
▪ Those that are ovarian in origin probably
sidewall
o Uterine involvement originated from mucinous tumors arising in
teratomas
▪ Synchronous primary tumors of low histologic
grade, usually of endometrioid type, with o 3 primary pathways for lymphatic drainage
involvement limited to endometrium and ovary
▪ Main lymphatics follow ovarian veins → paraaortic
– Favorable prognosis; often no additional
and aortocaval lymph nodes at level of renal veins
treatment following hysterectomy and
▪ Through broad ligament → pelvic lymph nodes,
oophorectomy
▪ Tumors metastasizing from uterus to ovary or from including external iliac, hypogastric, and obturator
nodes
ovary to uterus
▪ Along round ligament → inguinal lymph nodes
– Worse prognosis; adjuvant therapy is generally
indicated following hysterectomy and • Hematogenous spread
o Least common mode of spread
oophorectomy
o Usually not present at initial diagnosis, can be found
▪ Distinction between primary vs. secondary
involvement relies on histological examination at restaging
▪ In up to 50% of patients at autopsy
• Peritoneal seeding
o Most common mode of tumor spread General Features
▪ ~ 70% of patients have peritoneal metastases at
5 staging laparotomy
• Genetics
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Obgyne Books Full
Ovary
o Lifetime risk of ovarian cancer: 15-30% in women – Growing body of evidence suggests that HG-
carrying genes responsible for most hereditary SC arise from precursors located at fimbrial
ovarian cancers (BRCA1, BRCA2) end of fallopian tubes, called serous tubal
o Hereditary nonpolyposis colon cancer (Lynch intraepithelial carcinoma (STIC)
syndrome) has also been associated with endometrial – HG-SCs constitute 90% of all serous carcinomas
and ovarian cancers • Epidemiology & cancer incidence
• Etiology o ~ 3% of all cancers among women
o No known causative factor in development of o 2nd most common gynecological malignancy after
ovarian carcinoma endometrial carcinoma
o Factors known to increase risk of developing ovarian ▪ Estimated 22,240 new cases in USA in 2013
cancer o Leading cause of death from gynecological cancers
▪ Family history is strongest known risk factor and 9th leading cause of cancer death in women
– ~ 10% of cases are thought to have hereditary ▪ Estimated 14,030 deaths in USA in 2013
basis
– Women who have had breast cancer or who have
family history of breast or ovarian cancer are at IMAGING FINDINGS
increased risk
▪ Nulliparity, early menarche, and late menopause Detection
▪ Estrogen use alone as postmenopausal hormone • Primary goal of radiologic assessment is differentiation
therapy of malignant from benign tumors
▪ Obesity may be associated with increased risk • CA125 is glycoprotein that is assessed by monoclonal
▪ Pregnancy and long-term use of oral contraceptives antibody OC125
reduce risk of developing ovarian cancer o ↑ CA125 serum level ≥ 30 U/mL indicates presence of
o Endometriosis is associated with clear cell and malignancy
endometrioid variants in 49% and 28% of cases, o False-positive results
respectively ▪ In women with conditions affecting peritoneal
o It appears that both low-grade and high-grade pelvic surface, such as endometriosis
serous carcinomas that have traditionally been o False-negative results
classified as ovarian in origin actually originate, at ▪ In women with early-stage invasive disease and
least in a significant subset, from distal fallopian tube borderline ovarian tumors
o Dualistic model of ovarian carcinogenesis has been • General imaging findings suggestive of malignancy
proposed that classifies ovarian carcinomas into 2 o Most predictive imaging findings for malignancy are
groups ▪ Solid mass, especially when necrosis is present
▪ Type I ▪ Presence of nonfat nodular components in cystic
– Include low-grade serous carcinomas (LG-SCs), lesion
low-grade endometrioid carcinomas, clear cell o Other findings suggestive of malignancy
and mucinous carcinomas, and Brenner tumors ▪ Irregular, thick wall or septa (> 3 mm)
– Not clinically aggressive ▪ Vascularity in solid mass or papillary projections
– Generally present at early stage – Doppler demonstration of blood flow
– Rarely harbor TP53 mutations, but instead – Enhancement on CT and MR
display mutations involving specific cell o Ancillary findings that are strong indicators of
signaling pathways, including KRAS, BRAF malignancy
– LG-SC is thought to develop in a stepwise ▪ Ascites
fashion, sequentially from ovarian epithelial ▪ Peritoneal metastases
inclusions (OEIs) or serous cystadenoma, then ▪ Lymphadenopathy
to serous borderline tumor, and eventually to ▪ Pelvic organ or sidewall invasion
invasive carcinomas • Ultrasound
– Majority of OEIs are derived from fallopian tube, o Low cost and wide availability
and the tubal secretory cell is likely cell origin of o Modality of choice to evaluate suspected or palpable
LG-SC adnexal mass
– LG-SCs account for ~ 10% of all ovarian serous ▪ Adnexal masses are found on US in ~ 10% of
cancers premenopausal women
▪ Type II ▪ US seems to be similar with CT and MR in
– Include high-grade serous carcinomas (HG-SCs), differentiation of malignant from benign ovarian
high-grade endometrioid carcinomas, malignant tumors
mixed mesodermal tumors (carcinosarcomas), – Pattern recognition on US correctly classifies
and undifferentiated carcinomas 93% of lesions as benign or malignant (in
– Highly aggressive neoplasm experienced hands)
– Almost always present at an advanced stage o Transvaginal ultrasound (TVUS) and transabdominal
– Frequently display TP53 mutations and are ultrasound (TAUS) should be used together
genetically unstable ▪ TVUS allows best evaluation of pelvic masses but
has limited field of view
▪ TAUS is better for large mass or if ovaries are
displaced by enlarged leiomyomatous uterus
5
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Obgyne Books Full
o Ovarian volumes – Include enhancement amplitude (EA), time of
▪ Premenopausal women: Up to 20 cm³ half rising (Tmax), and maximal slope (MS)
▪ Postmenopausal women: Up to 8-10 cm³ ▪ Invasive tumors tend to show early intense and
▪ Ovarian volumes progressively decrease with age persistent enhancement
and years since menopause • FDG PET/CT
▪ Enlarged ovary for age, or ovary > 2x volume of o May detect unexpected ovarian cancers during
other ovary, may be early indication of ovarian staging of other tumors
neoplasm o Low specificity since benign lesions, such as corpus
o Spectral Doppler findings suggestive of malignancy luteum cyst in premenopausal women, can increase
▪ Low-resistance waveforms due to tumor ovarian uptake
neovascularity and arteriovenous shunting ▪ Increased ovarian FDG uptake in postmenopausal
▪ Resistance index < 0.4 and pulsatility index < 1 women, in whom benign lesions are less likely, is
▪ Considerable overlap with benign physiological usually associated with malignancy
lesions o May detect ovarian carcinoma in so-called normal-
▪ More suspicious in postmenopausal women, in sized ovary carcinoma syndrome (NOCS)
whom benign lesions are less frequent ▪ NOCS occurs when diffuse metastatic malignant
▪ Color Doppler flow imaging alone is significantly disease with normal-sized ovaries is noted, but no
inferior to combined US techniques, morphologic origin is assigned by preoperative or intraoperative
assessment alone, and contrast-enhanced US in evaluation
diagnosis of ovarian cancer
o Hemorrhagic cysts may appear similar to neoplasm Staging
▪ Repeat scanning 4–6 weeks following initial • Staging is surgical, based on International Federation of
detection of indeterminate ovarian mass Obstetrics and Gynecology (FIGO) system
o Mixed results reported for use of US ± CA125 in o Staging requires staging laparotomy, which includes
▪ Total abdominal hysterectomy
screening for ovarian cancer
▪ Bilateral salpingo-oophorectomy
▪ Routine US screening of asymptomatic women → ↑
▪ Omentectomy
false-positive results → unnecessary laparoscopy or
▪ Retroperitoneal lymph node sampling
laparotomy
▪ Peritoneal and diaphragmatic biopsies
▪ Positive predictive value for invasive cancer is 3.7%
▪ Cytological evaluation of peritoneal washings
for abnormal CA125, 1% for abnormal TVUS, and
• Preoperative imaging staging of ovarian carcinoma
23.5% if both tests are abnormal o CT is primary imaging modality for preoperative
• CT staging of ovarian cancer
o Increased number of incidental ovarian lesions
o MR is at least as accurate as CT
discovered due to widespread use of CT
▪ Used when CT is contraindicated
o Recent advances in CT technology and availability of
– e.g., in patients with poor renal function or
multidetector CT (MDCT) allow better detection and
allergy to iodinated contrast
improved characterization of adnexal masses
▪ 3.0T MR can achieve staging of ovarian cancer
o MDCT: Sensitivity (90%), specificity (89%),
accuracy comparable to surgical staging
positive predictive value (78%), negative predictive
▪ Adding DWI to routine MR improves sensitivity
value (95%), and overall accuracy in diagnosing
and specificity for depicting peritoneal metastases
malignancy (89%)
– Sensitivity and specificity of 90% and 95.5%,
• MR respectively
o Used mainly as problem solving tool in setting of
– Peritoneal tumor shows restricted diffusion
sonographically indeterminate or complex adnexal
on DWI and ascites of low signal intensity,
mass
o Can provide tissue characterization based on signal increasing tumor conspicuity
o FDG PET/CT
properties
▪ FDG PET is limited in resolution and not optimal
▪ MR is superior to US and CT in differentiation of
for detecting lesions < 0.5 cm in size
benign from malignant masses o CT and pelvic MR have replaced barium enema
o Adequate evaluation of adnexal masses on MR
and intravenous pyelography (IVP) in preoperative
imaging requires
staging of ovarian cancer
▪ T1WI and T2WI to delineate pelvic anatomy and
• Goals of preoperative imaging
tumor o Detection of metastatic lesions
▪ Fat-saturated T1WI to distinguish between fat and
▪ Prevent understaging
hemorrhage
▪ Allow adequate intraoperative sampling of
▪ Gadolinium-enhanced T1WI to improve detection
suspected lesions
of solid components o Recognition of extensive, unresectable disease
o Dynamic contrast-enhanced MR imaging has been
• Factors that generally preclude optimal debulking
used to analyze perfusion of solid components
include
contained in ovarian tumors o Invasion of pelvic sidewall, rectum, sigmoid colon, or
▪ Can differentiate among benign, borderline, and
bladder
malignant tumors o Bulky peritoneal disease in
▪ Different parameters have been used
▪ Porta hepatis
5 ▪ Intersegmental fissure of liver
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Obgyne Books Full
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▪ Lesser sac ▪ Surrounds or distorts > 90% of the circumference
▪ Gastrosplenic ligament of iliac vessels
▪ Gastrohepatic ligament o Local extension is easier to identify with MR than
▪ Subphrenic space with either CT or US
▪ Small bowel mesentery ▪ Superior soft tissue contrast
▪ Supracolic omentum • Nodal disease
▪ Presacral space o Frequency of nodal metastases in T1 or T2 disease
o Suprarenal and splenic adenopathy ▪ ~ 15%; increases to 65% in patients with M1
o Hepatic and splenic (parenchymal), pleural, or disease
pulmonary metastases o Major limitation of CT and MR: Dependence on size
• Preoperative CT and MR imaging are highly accurate in of lymph node to determine nodal involvement
o Detection of inoperable tumor ▪ Enlarged lymph node is likely to be involved
o Prediction of suboptimal debulking ▪ Not possible to exclude metastatic disease in
• Role of radiologist is not to describe disease as normal-sized node
resectable or nonresectable but instead to alert o Using short axis size threshold of ≥ 1 cm to define
clinicians to presence of disease that may complicate abnormal lymph nodes
surgery or may preclude optimal debulking ▪ Sensitivity of preoperative CT (50%), MR (83%)
• Malignant ascites ▪ Specificity of preoperative CT (92%), MR (95%)
o Ascites can result from increased peritoneal fluid o Cardiophrenic nodes are detected in ~ 15% of
production by tumor, peritoneal metastases, or patients with advanced disease
decreased absorption ▪ Often indicates poor prognosis; usually considered
▪ Ascites can result from blockage of diaphragmatic stage IV disease
lymphatics, indicating stage III disease ▪ Enlargement is defined as short axis diameter of > 5
o Any peritoneal fluid in postmenopausal women and mm
more than small amount of fluid in premenopausal o Functional evaluation of lymph nodes
women is abnormal ▪ DWI MR is accurate in distinguishing malignant
o Presence of ascites: Positive predictive value (75%) for from benign pelvic lymph nodes
presence of peritoneal metastases ▪ FDG PET
• Peritoneal disease – Detect metastases in normal-sized lymph nodes
o Microscopic peritoneal disease is undetectable with – Verify malignant tissue in enlarged nodes
imaging • Small bowel involvement
o Small peritoneal implants ≤ 2 cm are difficult to o Commonly occurs and is frequent cause of morbidity
detect with imaging ▪ Either due to serosal implants or frank wall
o Omentum is most common site of peritoneal spread invasion
of tumor • Liver involvement
▪ Early omental disease o Important to distinguish implants on liver capsule
– Subtle, fine, reticular nodularity (stage III) from true parenchymal metastases (stage
▪ Advanced omental disease IV)
– Mass-like omental thickening (omental cakes) ▪ Capsular implants are considered resectable,
o Common sites of involvement should be carefully whereas parenchymal metastases generally are not
evaluated, including subphrenic space, mesentery, ▪ Capsular masses are usually smooth, well defined;
and paracolic gutters have elliptic or biconvex appearance and sharp
o Presence of ascites or calcifications of peritoneal interface with liver parenchyma
nodules make implants more conspicuous and easy ▪ Parenchymal metastases are less defined and
to detect surrounded by liver parenchyma
o Abnormal enhancement of peritoneum may be the ▪ Capsular metastases may invade liver parenchyma
only finding suggestive of peritoneal infiltration – Fuzzy interface between mass and liver
▪ Delayed contrast-enhanced images acquired 5 parenchyma
minutes after contrast administration, especially • Pleural effusion
with MR imaging, is an early sign of carcinomatosis o Most common finding in stage IV disease
o Pseudomyxoma peritonei o Presence of effusion is not sufficient for designation
▪ Accumulation of mucinous ascites → hepatic, of stage IV disease
splenic, and mesenteric scalloping ▪ Cytologic evaluation is required
▪ When found, should raise possibility of primary o Pleural masses, nodularity, or thickening makes
appendiceal neoplasm with ovarian metastases likelihood of pleural metastases extremely high
rather than primary mucinous ovarian neoplasm
• Local extension Restaging
o Local tumor extension involving surrounding pelvic • Imaging recommendations
o Patients treated for ovarian cancer are followed up
organs is suggested by
▪ Distortion or irregular interface between tumor with serial measurements of CA125 and either CT
and myometrium scan or MR imaging of abdomen and pelvis
▪ Obscuration of tissue planes with either urinary ▪ Serial serum CA125 levels are accurate measure of
bladder or colon disease burden for most women
o PET/CT demonstrates greater accuracy and less
▪ < 3 mm between tumor and pelvic sidewall
interobserver variability than CT alone 5
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Obgyne Books Full
o Chest CT should not be performed routinely ▪ Good initial response to platinum-based
▪ Used if ↑ tumor markers and no sites of recurrence chemotherapy
are detected on abdominal and pelvic CT ▪ ~ 70% may recur
o MR is more sensitive than PET/CT for detecting local ▪ 5-year survival rate is ~ 10–20%
pelvic recurrence and peritoneal lesions in recurrent
ovarian carcinoma Treatment Options
• Treatment options by stage
o Stage I
CLINICAL ISSUES ▪ Total abdominal hysterectomy + bilateral salpingo-
oophorectomy + omentectomy
Presentation ▪ Undersurface of diaphragm should be visualized
• Symptoms are usually nonspecific and biopsied; pelvic and abdominal peritoneal
• Common symptoms biopsies and pelvic and paraaortic lymph node
o Abdominal pressure, fullness, swelling, or bloating biopsies are required
o Urinary urgency ▪ Peritoneal washings should be obtained routinely
o Pelvic discomfort or pain ▪ Unilateral salpingo-oophorectomy
o Women who experience such symptoms daily – Alternative for selected patients who desire
for more than a few weeks should seek medical childbearing and have grade I tumors on
evaluation histologic examination
• Other signs and symptoms – May be associated with ↓ risk of recurrence
o Persistent indigestion, gas, or nausea ▪ No further treatment if low-grade cancer; possible
o Unexplained changes in bowel habits, including combination chemotherapy if high-grade cancer
diarrhea or constipation o Stage II
o Changes in bladder habits, including urinary ▪ Total abdominal hysterectomy + bilateral salpingo-
frequency oophorectomy + debulking of as much tumor as
o Loss of appetite, unexplained weight loss or gain, possible + sampling of lymph nodes and other
increased abdominal girth suspected tissues
o Dyspareunia – Threshold diameter of 1 cm is used for acceptable
o Low back pain residual disease after debulking is shown to
o Abnormal vaginal bleeding is rarely symptom of correlate best with a good prognosis and long-
ovarian cancer term survival
▪ Following surgery, combination chemotherapy ±
Cancer Natural History & Prognosis radiation therapy
• Prognosis of ovarian cancer is generally poor, mainly ▪ Disease-free survival among patients who
due to late detection underwent neoadjuvant chemotherapy followed
o Percentage of tumor stage at diagnosis by debulking surgery is similar to that among
▪ Stage I (34%) patients who underwent initial surgery followed by
▪ Stage II (8%) adjuvant chemotherapy
▪ Stage III (43%) o Stage III
▪ Stage IV (11%) ▪ Same as stage II
• Staging is most important prognostic factor ▪ Possible follow-up surgery to remove any
o 5-year survival rate depends on tumor stage remaining tumor
▪ Stage IA (87.6%) o Stage IV
▪ Stage IB (84.5%) ▪ Debulking surgery to remove as much tumor as
▪ Stage IC (81.7%) possible, followed by combination chemotherapy
▪ Stage IIA (69.3%)
▪ Stage IIB (70.2%)
▪ Stage IIC (64.1%) REPORTING CHECKLIST
▪ Stage IIIA (52.2%)
▪ Stage IIIB (45.3%) T Staging
▪ Stage IIIC (32.1%) • Laterality
▪ Stage IV (15.3%) • Ascites
• For serous cystadenocarcinoma, prognosis depends on o Carefully inspect peritoneal surfaces for soft tissue or
whether tumor is LG-SC or HG-SC calcified nodules
o LG-SC • Involvement of uterus, rectum, bladder, or pelvic
▪ Behaves like a slow-growing indolent neoplasm sidewall
and has a better prognosis • Carefully check common sites of peritoneal implants
▪ Poor response to platinum-based neoadjuvant o DWI MR can be very useful in depicting peritoneal
chemotherapy implants
▪ ~ 30% may recur • Careful assessment of mesentery
▪ 5-year survival rate is ~ 40–56% o Infiltration of the mesenteric root precludes surgical
o HG-SC resection
▪ Biologically aggressive neoplasms, and they often
N Staging
5 manifest at an advanced stage
• Retroperitoneal lymph nodes, along ovarian veins
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Ovary
• Iliac lymph nodes, along broad ligament 15. Tsili AC et al: Adnexal masses: accuracy of detection and
• Inguinal lymph nodes, along round ligament differentiation with multidetector computed tomography.
• Enlargement of suprarenal lymph nodes, especially at Gynecol Oncol. 110(1):22-31, 2008
16. Kim CK et al: Detection of recurrent ovarian cancer at
level of celiac axis and porta hepatis
MRI: comparison with integrated PET/CT. J Comput Assist
o Frequently an indication for primary neoadjuvant
Tomogr. 31(6):868-75, 2007
chemotherapy 17. Liu J et al: Ultrasonography, computed tomography and
magnetic resonance imaging for diagnosis of ovarian
M Staging carcinoma. Eur J Radiol. 62(3):328-34, 2007
• Liver is common site of metastatic disease 18. Chen M et al: Differentiation between malignant and
o Capsular hepatic lesions are T3 disease benign ovarian tumors by magnetic resonance imaging.
o Hepatic parenchymal lesions are M1 disease Chin Med Sci J. 21(4):270-5, 2006
o Capsular lesions can invade into liver parenchyma to 19. Woodward PJ et al: From the archives of the AFIP: radiologic
become M1 disease staging of ovarian carcinoma with pathologic correlation.
• Chest CT if CT of abdomen and pelvis is negative and Radiographics. 24(1):225-46, 2004
20. Seidman JD et al: Pathology of ovarian carcinoma. Hematol
tumor markers are high
Oncol Clin North Am. 17(4):909-25, vii, 2003
o Nodular pleural thickening strongly suggests pleural
21. Coakley FV: Staging ovarian cancer: role of imaging. Radiol
metastases Clin North Am. 40(3):609-36, 2002
▪ But positive pleural cytology is a requirement for
M1 designation
o Hilar, mediastinal, or supraclavicular adenopathy is
considered M1 disease
SELECTED REFERENCES
1. Nik NN et al: Origin and pathogenesis of pelvic (ovarian,
tubal, and primary peritoneal) serous carcinoma. Annu Rev
Pathol. 9:27-45, 2014
2. American Cancer Society: Cancer Facts and Figures
2013. http://www.cancer.org/acs/groups/content/
@epidemiologysurveilance/documents/document/
acspc-036845.pdf. Accessed October 7, 2013
3. Espada M et al: Diffusion-weighted magnetic resonance
imaging evaluation of intra-abdominal sites of implants to
predict likelihood of suboptimal cytoreductive surgery in
patients with ovarian carcinoma. Eur Radiol. 23(9):2636-42,
2013
4. Li J et al: Ovarian serous carcinoma: recent concepts on its
origin and carcinogenesis. J Hematol Oncol. 5:8, 2012
5. Nougaret S et al: Ovarian carcinomatosis: how the
radiologist can help plan the surgical approach.
Radiographics. 32(6):1775-800; discussion 1800-3, 2012
6. Lalwani N et al: Histologic, molecular, and cytogenetic
features of ovarian cancers: implications for diagnosis and
treatment. Radiographics. 31(3):625-46, 2011
8. Low RN et al: Diffusion-weighted MRI of peritoneal tumors:
comparison with conventional MRI and surgical and
histopathologic findings--a feasibility study. AJR Am J
Roentgenol. 193(2):461-70, 2009
9. Suga K et al: F-18 FDG PET-CT findings in a case of
normal-sized ovarian cancer syndrome. Clin Nucl Med.
34(10):706-9, 2009
10. Booth SJ et al: The accurate staging of ovarian cancer using
3T magnetic resonance imaging--a realistic option. BJOG.
115(7):894-901, 2008
11. Ferreira CR et al: Mucinous ovarian tumors associated
with pseudomyxoma peritonei of adenomucinosis type:
immunohistochemical evidence that they are secondary
tumors. Int J Gynecol Cancer. 18(1):59-65, 2008
12. Fujii S et al: Detection of peritoneal dissemination in
gynecological malignancy: evaluation by diffusion-
weighted MR imaging. Eur Radiol. 18(1):18-23, 2008
13. Sebastian S et al: PET-CT vs. CT alone in ovarian cancer
recurrence. Abdom Imaging. 33(1):112-8, 2008
14. Thomassin-Naggara I et al: Dynamic contrast-enhanced
magnetic resonance imaging: a useful tool for characterizing
5
ovarian epithelial tumors. J Magn Reson Imaging.
28(1):111-20, 2008
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(Left) Longitudinal color
a mixed solid-cystic left
ovarian mass with a large
solid component. There is
blood flow within both the
solid component and
the wall . The other ovary
was normal; there is no
ascites. (Right) Longitudinal
shows increased blood flow
within a mixed solid-cystic
right ovarian mass. The
Doppler wave form shows
low-resistance flow of 0.2 due
to tumor neovascularity and
vascular shunting.

(Left) Axial PET/CT in a
55-year-old patient with
a history of breast cancer
shows an incidental finding of
a slightly enlarged left ovary
with an area of increased
metabolic activity . (Right)
patient shows increased focal
ovarian metabolic activity .
This finding is not specific
and can be seen in the
setting of benign or malignant
disease. However, such
findings are more specific in
postmenopausal women, in
whom benign lesions are less
likely.

large cystic ovarian mass
with thick septa and
no evidence of peritoneal
metastases. (Right) Axial
shows a soft tissue mass
filling the endometrial
cavity . Histological
examination showed low
histological grade of both
tumors, with associated
atypical endometrial
hyperplasia and ovarian
endometriosis, findings that
favor independent primary
tumors. Streak artifacts
result from metallic hip
replacement.
5
52
Obgyne Books Full
Ovary
long history of pelvic pain
shows a complex left ovarian
multilocular cystic lesion
. One of the cystic
compartments is of very
high signal intensity, while
another compartment is
slightly hyperintense relative
to muscles. Note a small
papillary projection
within the 2nd compartment.
(Right) Axial T1WI FS
shows 2 hyperintense
cystic compartments due to
endometriomas.

same patient shows low T2
signal intensity of the 1st
compartment and high
T2 signal intensity of the
2nd compartment . The
high T1 signal intensity and
low T2 signal intensity (T2
shading) is characteristic of
endometriomas. Note the
small intracystic papillary
lesion . (Right) Coronal
shows the multilocular cystic
mass and the intracystic
papillary lesion .

enhancement of the small
papillary lesion within the
cyst. (Right) Coronal T1 C+
intracystic papillary lesion .
This was proven at surgery
to be clear cell carcinoma.
Clear cell and endometrioid
adenocarcinoma are the 2
histologic types that develop
within endometriomas.
5
53
Obgyne Books Full

bilateral, ovarian,
multilocular, mainly
cystic masses with
loculi exhibiting different
attenuation. The right ovary
has 2 loculi; the more
anterior loculus has
higher attenuation than the
more posterior loculus .
ovarian masses . The
presence of multiple loculi
of different attenuation in an
ovarian mass is a feature of
mucinous tumors.
Stage IC (T1c N0 M0) Stage IC (T1c N0 M0)

a large left ovarian mass that
is partially solid and partially
cystic . A small amount
of ascitic fluid is seen in
the cul-de-sac . (Right)
Coronal T2WI MR in the
same patient shows a mixed
solid-cystic ovarian mass
with mural nodules . At
surgery, malignant cells were
found in the ascitic fluid. The
size of an ovarian mass does
not affect staging as long as
the tumor is limited to the
ovary and there is no capsular
rupture.

heterogeneous left ovarian
mass and another
heterogeneous mass
that fills the uterine cavity.
Histology revealed a primary
ovarian tumor with metastasis
to the uterus. (Right) Axial
shows an omental mass
confined to the pelvis .
Uterine involvement alone
would constitute T2a disease,
but the presence of pelvic
omental involvement makes
this T2b disease.
5
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Obgyne Books Full
Ovary
left heterogeneous ovarian
mass separate from
the uterus . There is no
ascites. (Right) Axial CECT
infiltrating mass involving
the sigmoid mesocolon. The
mass does not extend to the
sigmoid colon .

5 cm unilocular, cystic, left
ovarian mass without
obvious septa or mural
nodules. This is a relatively
benign appearance. (Right)
patient shows subtle omental
nodules , indicating
T3b disease. The presence
of omental disease is
surprising given the rather
benign appearance of the
ovarian cystic mass. Surgery
confirmed a malignant clear
cell ovarian carcinoma with
peritoneal disease outside the
pelvis.

(Left) Axial CECT shows small
calcified peritoneal implants
along the liver capsule
and in the splenic hilum .
same patient shows calcified
small peritoneal metastases
along the falciform ligament
. The calcifications make
otherwise small, undetectable
peritoneal implants more
conspicuous. The presence of
calcified peritoneal implants
is characteristic of metastatic
serous cystadenocarcinoma.
5
55
Obgyne Books Full

nodular thickening of the
omentum . (Right) Axial
shows ascites with
nodular peritoneal thickening
in a patient with primary
peritoneal carcinoma, an
unusual tumor of histiogenic
origin similar to primary
ovarian carcinoma. It diffusely
involves the peritoneum but
spares or only superficially
involves ovaries. Generally
diagnosed in the state of
peritoneal carcinomatosis, it
has a poor prognosis.
t
ne
Stage IIIC (T3c N0 M0) Stage IIIC (T3c N0 M0)
e.
yn
with abdominal distension
and was found to have pelvic
masses on vaginal exam
shows a mixed solid and
bg
cystic right ovarian mass .
Ascites is present . The
mass displaces the colon
ko
without obvious invasion.
same patient shows another
mass superior to the right
oo
ovarian mass. The left ovarian

vein can be traced to this
mass, thereby establishing its
eb
origin from the left ovary.

://

tp

patient shows a 3rd mass
within the abdomen that
ht
represents an abdominal
peritoneal metastasis larger
than 2 cm. Subtle omental
nodularity is also present.
left ovarian mass with a
separate peritoneal metastatic
lesion .
5
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Ovary
large perihepatic peritoneal
implants . Note the
sharp interface between
the implants and the liver.
Ascites is also present. (Right)
Coronal reformat CECT in
a perihepatic peritoneal
implant indenting the
liver parenchyma but without
parenchymal invasion.
Perihepatic ascites is also seen
. Coronal reformat better
delineates capsular implants
and confirms the peritoneal,
rather than pleural, location.
t
ne
Stage IIIC (T1a N1 M0) Stage IIIC (T1a N1 M0)
e.
a large, cystic left ovarian
yn
lesion extending into the
abdomen and displacing
the bowel loops on both
sides. There was no ascites
bg
or evidence of peritoneal
ko
shows an enlarged left
inguinal lymph node .
Metastases to inguinal nodes
result from tumor spread
oo
through lymphatics along the

round ligament.
eb
://
Stage IIIC (T2b N1 M0) Stage IIIC (T2b N1 M0)

tp

a large, solid mass arising
from the left ovary . The
ht
mass displaces the sigmoid

colon and is < 3 mm from
the left obturator internus
muscle . Involvement of
the pelvic sidewall makes
the tumor inoperable in most
institutions. Extensive pelvic
involvement constitutes T2b
disease. (Right) Axial CECT
an enlarged left paraaortic
lymph node . Regional
nodal metastases constitute
N1 disease.
5
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mixed solid and cystic
right ovarian mass with thick
septa within the cystic
component. (Right) Axial
shows the large multilocular
cystic component of the
mass with solid tumor
invading into the wall of the
sigmoid colon . There is
also an enlarged right internal
iliac lymph node .
t
ne
e.
patient with advanced local
yn
disease shows invasion of
the myometrium . The
tumor is < 3 mm from the
pelvic side wall . The
bg
rectum is displaced but
not invaded. Bilateral external
iliac lymphadenopathy
ko
indicates N1 disease. (Right)
patient shows invasion of the
posterior wall of the uterus
oo
sparing the endometrium

. The urinary bladder is
not involved.
eb
://

tp

large mass occupying almost
ht
the entire pelvis. There is an

irregular interface between
the tumor and the uterus
due to uterine invasion. The
tumor comes within 3 mm
of the pelvic sidewall .
Bilateral external iliac nodes
are also seen . (Right) Axial
patient shows enhancing
tumor invading and
wrapping around the rectum
to involve the uterosacral
ligament .
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Ovary
Stage IIIC (T3c N1 M0) Stage IIIC (T3b N1 M0)
with advanced ovarian
carcinoma demonstrates a
10 mm left inguinal lymph
node . This node is not
pathologic by any size
criterion. Note the small
anterior abdominal wall
postoperative subcutaneous
seroma . (Right) Coronal
PET in the same patient
shows extensive peritoneal
metastatic disease .
Peritoneal lesions are < 2 cm
in greatest dimension. The
left inguinal node shows
increased metabolic activity.
t
ne
Stage IV (T3c N0 M1) Stage IV (T3c N0 M1)
e.
(Left) Axial CECT shows large
bilateral multilocular ovarian
yn
masses with internal
septations . (Right) Axial
shows omental metastases
bg
with a large omental mass
invading the fundus of
the gallbladder . Large
ko
peritoneal metastases (> 2
cm) within the abdomen
constitute T3c disease, and
invasion of the gallbladder
oo
constitutes M1 disease.
eb
://

tp

with advanced local disease
shows multiple poorly
ht
enhancing parenchymal liver

lesions . Intraparenchymal
liver lesions constitute M1
disease. (Right) Axial CECT
multiple parenchymal hepatic
lesions . Note the right-
sided pleural effusion
and pleural nodules .
The presence of malignant
pleural effusion constitutes
M1 disease. Pleural nodularity
is highly suggestive of pleural
metastases.
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with recurrent ovarian
carcinoma and multiple large
peritoneal implants shows
that 1 lesion invades
the posterior wall of the
stomach. Another lesion
involves the omentum,
and 2 lesions involve the
gastrohepatic ligament. Also
note the dilated common bile
duct . (Right) Axial CECT
that the common bile duct
dilatation is due to a subtle
parenchymal pancreatic head
mass .
t
ne
e.
yn
a relatively hyperintense
peritoneal implant
invading the posterior
wall of the stomach .
bg
The common bile duct is
markedly dilated . (Right)
ko
patient shows a hyperintense
intraparenchymal pancreatic
head mass .
oo
eb
://

tp

multiple peritoneal implants
ht
involving the posterior wall

of the stomach , omentum
, and gastrohepatic
ligament . Note that the
lesions are poorly enhancing
after contrast administration.
shows a similarly poorly
enhancing intraparenchymal
pancreatic head mass ,
causing common bile duct
obstruction.
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Ovary
Stage IV (T3a N1 M1) Stage IV (T3a N1 M1)
patient with advanced
local disease (not shown)
demonstrates bilateral
hilar and subcarinal
lymphadenopathy.
Note also the right-sided
pleural effusion . (Right)
patient shows prevascular
mediastinal lymphadenopathy
. Right-sided pleural
effusion is seen . The
presence of mediastinal
metastatic disease constitutes
M1 disease.
t
ne
Stage IV (T3b N1 M1) Stage IV (T3c N1 M1)
e.
enlarged cardiophrenic lymph
yn
nodes . A cardiophrenic
node > 5 mm is suspicious
for metastatic disease. Right-
sided pleural effusion is also
bg
seen . Many consider
metastatic disease to the
cardiophrenic node to be M1
ko
disease. (Right) Axial CECT in
a patient with advanced local
disease shows an enlarged
left supraclavicular lymph
oo
node . Metastatic disease

to supraclavicular nodes
constitutes M1 disease.
eb
://

tp

a liver capsular implant
invading into the liver
ht
parenchyma. An ill-defined
interface between the
capsular implant and the
underlying liver parenchyma
indicates liver invasion and
stage IV disease. (Right) Axial
shows 2 peritoneal implants.
The 1st invades the right
diaphragm , and the 2nd
involves the gastrosplenic
ligament . Gastrosplenic
ligament implants indicate
inoperable disease.
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Ovary SEROUS CYSTADENOMA
Key Facts
• Benign lesion classified as epithelial ovarian neoplasm • Functional cysts of ovary
Imaging • Paratubal cyst
• Usually indistinguishable from functional ovarian • Low malignant potential and malignant serous tumors
• Endometrioma
• Mucinous tumors
cysts
o Smooth, thin-walled, unilocular ovarian cyst
• 12-20% are bilateral • Mature teratoma
• Anechoic, unilocular thin-walled cyst with posterior Clinical Issues
•
acoustic enhancement on US
Fluid attenuation on CECT • Curative cystectomy or oophorectomy
• Cyst contents demonstrate fluid signal intensity on Diagnostic Checklist
MR sequences • Serous cystadenoma for persistent simple cyst > 6 cm
o Papillary projections, if present, enhance following
contrast
• To document persistence: Repeat US performed 6
weeks after initial observation
• US for initial evaluation
t
ne
e.
yn
pelvic color Doppler
ultrasound shows a right
ovarian anechoic unilocular
bg
cystic lesion with
imperceptible wall. Blood
flow is present in the thin rim
ko
of ovarian tissue around
the lesion, but no flow is
seen in the cyst wall. There
are no septations or mural
oo
nodules. (Right) Axial CECT in

a 45-year-old woman shows
bilateral unilocular ovarian
eb
cystic lesions with a thin

wall and no internal septations
or mural nodules.
://
tp
ht

27-year-old woman shows
a multilocular cystic ovarian
mass with thin septations
and no mural nodules. (Right)
Axial T2WI MR in a 23-
year-old woman shows a
right ovarian cystic mass
composed of 2 locules
separated by a thin septum
. Ovarian tissue is seen
at the anterior aspect of the
cystic mass.
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SEROUS CYSTADENOMA
Ovary
o Many reports describing iodine uptake in benign
TERMINOLOGY
ovarian cystadenomas
Definitions
• Benign ovarian tumor classified as epithelial ovarian • Best imaging tool
neoplasm
o US for initial evaluation
• Thin-walled, serous fluid-containing cyst(s) lined by ▪ Transvaginal ultrasound (TVUS) usually better
single layer of epithelium
than transabdominal ultrasound in evaluation of
cystic ovarian lesions
IMAGING o MR imaging useful adjunct to US to improve tissue
characterization
General Features
o Imaging appearance is usually indistinguishable from DIFFERENTIAL DIAGNOSIS
functional ovarian follicular cysts
o Smooth, thin-walled, usually unilocular ovarian cyst Functional Cysts of Ovary
▪ Can be multilocular • Follicular cysts or corpus luteum cysts may mimic
o Persist on follow-up examinations cystadenoma
o Functional cysts typically resolve over 1-2 menstrual
▪ Most important factor in differentiating serous
cycles, whereas cystadenomas will persist unchanged
t
cystadenoma from ovarian physiologic cysts
• or grow
ne
Location
▪ Recommend US follow up in 4-6 weeks
o 12-20% of all cases are bilateral o Corpus luteum cysts tend to show observable flow
• Size in wall on color Doppler and have thicker wall than
o Variable, up to 30-50 cm
e.
serous cystadenomas
▪ Average size: 10 cm ▪ Presence of papillary projections and nodular septa
• Morphology should suggest an ovarian neoplasm
yn
o Thin-walled cysts
o Usually unilocular but may be multilocular Paratubal Cyst
• Paratubal cysts are separate from ovary
CT Findings
bgo Every effort should be made during TVUS to separate
• Appears as nonspecific ovarian cyst with homogeneous cyst from ovary by pushing transducer between cyst
fluid density and ovary to establish its extraovarian location
• Cyst wall is thin or imperceptible (< 3 mm)
ko
• Fairly homogeneous and lacking internal structures Low Malignant Potential and Malignant Serous
o No septations or solid elements Tumors
• Features that are more suggestive of benign epithelial
oo
MR Findings tumors include

• T1WI o Size < 4 cm
o Cyst contents are usually low signal intensity o Unilocular
eb
▪ May be higher in signal intensity if complicated o Entirely cystic with no solid components
• T2WI o Wall thickness < 3 mm
o Thin regular wall or septum and usually no o Lack of internal structure
://
endocystic or exocystic vegetation o Absence of both ascites and invasive characteristics

▪ Cyst contents show high signal intensity such as peritoneal disease or adenopathy
• T1WI C+
tp
o Enhancing thin wall and septa Endometrioma

• May appear as a unilocular cyst or multilocular cysts
Ultrasonographic Findings o MR
ht
• Grayscale ultrasound ▪ T1WI

o Anechoic, unilocular thin-walled cyst with posterior – Cyst contents show very high signal intensity
acoustic enhancement ▪ T2WI
• Pulsed Doppler – Cyst contents show low signal intensity
o High-resistance flow on pulsed wave Doppler (shading), a rare pattern in serous cystadenomas
imaging o TVUS
▪ Higher resistive indices and pulsatility indices than ▪ Classic carpeting of low-level echoes ± avascular
malignant neoplasms mural nodules
• Color Doppler Mucinous Cystadenoma
o No apparent flow in cyst wall
• Usually larger and multiloculated
Nuclear Medicine Findings • Variable densities or signal within loculations on CT
• PET and MR owing to mucinous debris and hemorrhage
o Usually no increased metabolic activity on FDG PET ("stained glass" appearance)
o Occasional cases of uptake have been described • TVUS demonstrates regions of varying echogenicity
• Iodine-131 scan
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Mature Teratoma Natural History & Prognosis

• Readily recognized on CT by presence of fat and • Do not recur after oophorectomy
calcifications • Low-grade serous cystadenocarcinoma is thought
• MR to evolve in stepwise fashion from OEIs/serous
o T1WI cystadenomas to serous borderline tumors to invasive
▪ High signal intensity due to presence of fat carcinoma
▪ Fat-suppressed scans are diagnostic and confirm
Treatment
• Curative cyst resection or oophorectomy
presence of fatty elements
o T2WI: Intermediate signal intensity
• TVUS: Cystic adnexal mass containing an echogenic
focus with distal acoustic shadowing DIAGNOSTIC CHECKLIST
Consider
PATHOLOGY
• Serous cystadenoma for persistent simple cyst > 6 cm
General Features o To document persistence: Repeat US performed 6
• Etiology weeks after initial observation
o Majority of serous cystadenomas are thought to be • Torsion or rupture in patients presenting with ovarian
derived from ovarian epithelial inclusions (OEIs) cyst and acute pelvic pain
▪ Both display morphologically and o Twisting of vascular pedicle and enlargement of
t
ne
immunophenotypically similar epithelial lining ovary in cases of torsion
▪ Diagnostic criterion separating OEIs from serous o Collapse of cyst and pelvic or abdominal fluid in
cystadenoma is arbitrarily made at 1 cm size cases of rupture
e.
threshold Image Interpretation Pearls
o OEIs are thought to be derived from fallopian tube
epithelium
• Persistent or slow-growing simple cyst suggests serous
yn
cystadenoma
• Average 10 cm in diameter but may be very large and SELECTED REFERENCES
fill pelvis and abdomen
bg
• Usually unilocular but can be multilocular 1. Haaga TL et al: Benign ovarian serous cystadenoma
• Linings are smooth or have small papillary projections

mimicking papillary thyroid carcinoma metastasis on I-131
SPECT/CT. Med Health R I. 95(2):57-9, 2012
ko
2. Li J et al: Ovarian serous carcinoma: recent concepts on its
• Cyst lining is composed of a single layer of benign
origin and carcinogenesis. J Hematol Oncol. 5:8, 2012
epithelium features of ovarian cancers: implications for diagnosis and
• Epithelium tends to form papillary structures
oo

• Epithelium resembles fallopian tube mucosa 4. Saunders BA et al: Risk of malignancy in sonographically
• Wall of cyst is composed of fibrous stroma confirmed septated cystic ovarian tumors. Gynecol Oncol.
eb
• Psammomatous calcifications are present in ~ 15%

118(3):278-82, 2010
5. Diamantopoulou S et al: Serous cystadenoma with massive
of benign tumors microscopically and occasionally ovarian edema. A case report and review of the literature.
macroscopically Clin Exp Obstet Gynecol. 36(1):58-61, 2009
://
6. Dorum A et al: Prevalence and histologic diagnosis of

adnexal cysts in postmenopausal women: an autopsy study.
CLINICAL ISSUES Am J Obstet Gynecol. 192(1):48-54, 2005
tp
7. Fenchel S et al: Asymptomatic adnexal masses: correlation

Presentation of FDG PET and histopathologic findings. Radiology.
• Most common signs/symptoms 223(3):780-8, 2002
ht
o Usually asymptomatic 8. Jung SE et al: CT and MR imaging of ovarian tumors

• Other signs/symptoms with emphasis on differential diagnosis. Radiographics.
22(6):1305-25, 2002
o If large, may cause mass-related symptoms
9. Jeong YY et al: Imaging evaluation of ovarian masses.
o Rarely, acute pelvic pain due to adnexal torsion
Radiographics. 20(5):1445-70, 2000
Demographics 10. Yamashita Y et al: Adnexal masses: accuracy of
• Age characterization with transvaginal US and precontrast and

postcontrast MR imaging. Radiology. 194(2):557-65, 1995
o Can be encountered at any age, but peak incidence in 11. Kurman RJ et al: The behavior of serous tumors of low
4th & 5th decades malignant potential: are they ever malignant? Int J Gynecol
o Account for significant proportion of incidental cysts Pathol. 12(2):120-7, 1993
in postmenopausal women
▪ Up to 84% of simple adnexal cysts in
postmenopausal women are serous cystadenomas
at surgery
• Epidemiology
o Account for 25% of all benign ovarian neoplasms
o ~ 50-70% of serous tumors are benign
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SEROUS CYSTADENOMA
Ovary
year-old woman, who had a
persistent right ovarian cystic
lesion on an US performed
6 weeks after her initial US
examination, shows a unilocular
T2 hyperintensity right ovarian
cystic lesion with thin wall
and no visible mural nodules
or septations. (Right) Sagittal
shows the right ovarian lesion
. Normal ovarian tissue is
seen above the lesion with claw
of ovarian tissue surrounding
the lesion, indicating its ovarian
t
origin.
ne
e.
yn
same patient shows the right
ovarian lesion to have
bg uniform low T1 signal intensity.
peripheral enhancement of the
ko
thin cyst wall . No enhancing

septa or solid component
are seen. The appearance of
oo
serous cystadenoma on MR is
indistinguishable from follicular
cyst. Because of the persistence
of the cyst over a 4-month
eb
period, the diagnosis of serous

cystadenoma was suggested
and was confirmed after cyst
resection.
://
tp
ht

with a palpable mass shows a
multilocular ovarian mass
with thin septa and no mural
nodules. (Right) Axial T1WI C+
FS MR in the same patient shows
the multilocular cystic mass .
Different T1 signal intensities in
the locules is unusual for serous
cystadenomas, and locules with
high T1 signal intensity are likely
due to hemorrhage.
5
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Obgyne Books Full

year-old perimenopausal
woman shows a 4.5 cm left
ovarian unilocular fluid density
lesion . The lesion shows
homogeneous fluid attenuation
without visible septations
or mural nodules. Ovarian
tissue is present at the
periphery of the lesion. (Right)
Coronal CECT in the same
patient shows the left ovarian
cystic lesion . Follow-up
ultrasound at 6 weeks was
recommended and showed
persistence of the lesion.
t
Histological examination
ne
revealed serous cystadenoma.
e.
yn
old perimenopausal woman
shows a 17 cm left ovarian
unilocular fluid attenuation
bg
lesion . The lesion shows
homogeneous fluid attenuation
without visible septations or
ko
mural nodules. (Right) Coronal

shows a homogeneous fluid
oo
density left ovarian cystic

lesion . Because of its large
size, the lesion was resected
and histological examination
eb
revealed serous cystadenoma.

://
tp
ht

with acute lower abdominal
pain shows a unilocular pelvic
cystic mass located anterior
to the uterus. (Right) Coronal
shows the cystic pelvic mass
with twisting of the left
adnexal vascular pedicle ,
suggestive of torsion. Ovarian
torsion due to large serous
cystadenoma was confirmed
at surgery. The possibility of
torsion should be considered
in patients presenting with a
large ovarian cyst and acute
pain.
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SEROUS CYSTADENOMA
Ovary
pelvic pain shows an enlarged
left ovary (8 cm) and a small
amount of free fluid within the
cul-de-sac . (Right) Axial
CECT in the same patient at a
higher level shows a unilocular
cystic structure continuous
with the enlarged ovary.
t
ne
e.
yn
(Left) Coronal CECT in the same
patient shows the enlarged
left ovary containing the
bg large cyst with multiple
ovarian follicles . (Right)
Sagittal CECT in the same patient
shows the enlarged ovary
ko
and the attached ovarian cyst

. Ovarian torsion due to
ovarian serous cystadenoma was
oo
confirmed during surgery.

eb
://
tp
ht

acute pain shows a collapsed
left ovarian unilocular cystic
structure and a moderate
amount of free fluid within the
cul-de-sac and around the
lesion . (Right) Sagittal CECT
collapsed left ovarian cyst ,
demonstrating a crenulated
contour. Laparoscopy confirmed
ruptured left ovarian serous
cystadenoma.
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Ovary MUCINOUS CYSTADENOMA
Key Facts
Terminology o Cyst contents are generally low signal intensity on
• Classified as benign ovarian epithelial neoplasms T1WI
o T2 hyperintense cysts
Imaging o "Stained glass" appearance due to varying signal
• Usually unilateral intensities of cysts
• Can range widely in size • US
• Multilocular cystic mass with thin cyst wall and thin o Loculi may show low-level echoes and differing
echogenicity
septations
• Smooth-walled cysts of varying sizes Clinical Issues
• Presence of solid components or papillary projections • Palpable mass, increasing abdominal girth, and pelvic
suggest borderline or malignant tumor pain
• Bilateral mucinous tumors suggest borderline or • Acute presentations due to ovarian torsion include
malignant tumor pelvic pain and fever
• CT • 20-25% of all benign ovarian neoplasms and 75-85% of
o Mural calcifications can be seen all ovarian mucinous tumors
o Loculi contain fluid of varying attenuation
• Can occur at any age but are rare in young women and
•
t
MR children
• Excision is curative
ne
e.
yn
(Left) Axial graphic shows a
multilocular cystic mass
in the abdomen exhibiting
variable compositions
bg
within the loculi, resulting
in different attenuations/
signal intensities within the
ko
loculi, a characteristic imaging
feature of ovarian mucinous
cystadenoma. (Right)
Sagittal transvaginal color
oo

multilocular ovarian mass
with different echogenicities
eb
of the intracystic contents.

Blood flow is seen within a
thin septum .
://
tp
ht

large unilocular cyst filling
the pelvis and extending
into the abdomen. The cyst
has an imperceptible wall,
homogeneous fluid-attenuation
contents, and no internal
septations. (Right) Axial CECT
shows bilateral multilocular
cystic masses . The different
loculi in the left ovarian mass
show homogeneous fluid
attenuation, while those in
the right ovarian mass show
variable attenuation.
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MUCINOUS CYSTADENOMA
Ovary
o High-resistance waveforms with higher resistive
TERMINOLOGY
indices and higher pulsatility indices than malignant
Definitions tumors
• Classified as benign ovarian epithelial neoplasms ▪ However, there is considerable overlap in Doppler
findings between benign and malignant ovarian
tumors
IMAGING ▪ Lack of Doppler flow does not exclude malignancy
o Multilocular cyst with septations < 3 mm, often very o Ultrasonography is often sufficient to characterize
large and without solid components tumor
• Location ▪ MR may be performed if US is equivocal or
o Usually unilateral nondiagnostic
▪ Bilateral in 2-5% of cases ▪ CT is useful for staging if malignancy is being
• Size considered
o Can range widely in size o Extensive imaging evaluation is usually unnecessary
o Commonly large masses filling entire pelvis
• Morphology
t
o Typically multiloculated cystic mass
ne
o Smooth-walled cysts of varying sizes Serous Cystadenoma
o Presence of solid components or papillary • Tremendous overlap between imaging findings of
projections suggest borderline or malignant tumor serous and mucinous cystadenomas
o Bilateral mucinous tumors suggest borderline or
e.
malignant tumor Mucinous Cystadenocarcinoma
o Mucin-containing cysts can be complicated by • Papillary projections or solid components within
yn
hemorrhage or cellular debris tumor suggest borderline or malignant tumor
CT Findings Functional Cyst

• NECT • Follicular cysts and corpus luteum cysts
bg
o Mural calcifications can be seen Peritoneal Inclusion Cyst
▪ More common than in serous ovarian tumors
• Peritoneal pseudocysts are loculations of fluid which
•
ko
CECT occur around ovary in patients with paraovarian
o Multilocular cystic mass with thin cyst wall and thin adhesions due to endometriosis or prior surgery
septations
o Loculi contain fluid of varying attenuation
• Ovary will be intact within pseudocyst; in mucinous
oo
cystadenoma, ovary is not distinguished from mass

MR Findings Endometrioma
• T1WI • T1 high signal intensity due to hemorrhage
eb
o Cyst contents are generally low signal intensity

▪ Loculi may show higher signal intensity from
• T2 "shading": Decrease in signal intensity
concentration of mucinous components or Cystic Teratoma
• Characteristically contains fat
://
hemorrhage
• T2WI
Tubo-Ovarian Abscess
o T2 hyperintense cysts
• Complex cystic lesions in pelvis due to infection
tp
o "Stained glass" appearance due to varying signal

intensities of cysts • Patients usually present with fever, pelvic pain, and
ht
o Thin, regular septations elevated white blood cell count

o Lack of endocystic or exocystic vegetations • Stranding of pelvic fat on CECT and significant
• T1WI C+
enhancement of thick, irregular abscess wall
o Cyst walls and septations demonstrate enhancement Mucocele
but are thin and without nodularity • Dilated appendix filled with mucin
Ultrasonographic Findings • Usually tubular on funnel shaped
• Grayscale ultrasound • Can be traced to cecum at site of appendiceal
o Multiloculated cystic lesion attachment
o Loculi may show low-level echoes and differing
echogenicity PATHOLOGY
▪ Potential pitfall is echogenic locule mimicking
solid component General Features
o Papillary projections are less common than in serous • Etiology
cystadenomas o Etiology of mucinous ovarian tumors is not known
o Transabdominal ultrasound may be necessary in o Occasionally, mucinous tumors are associated with
evaluating full extent of larger tumors other ovarian tumors implying common origin
• Pulsed Doppler
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▪ Teratomas, granulosa cell, carcinoid, and Brenner DIAGNOSTIC CHECKLIST

tumors
▪ Appendiceal tumors may metastasize to ovary Consider
and cause mucinous ovarian tumor identical to • Mucinous cystadenoma when evaluating a large
mucinous cystadenomas multilocular cystic mass with variable appearance of
o Growing body of evidence that mucinous cystic material
cystadenomas can progress to borderline and
malignant tumors Image Interpretation Pearls
• Findings that suggest borderline rather than benign
Gross Pathologic & Surgical Features mucinous tumor
• Represent largest ovarian tumors: Up to 100 kg o More and smaller loculi (honeycomb loculi)
• Outer surface is lobulated o High signal intensity on T1WI, and low signal
• Internal surface is multiseptated or has cysts within intensity on T2WI of intracystic content
o Thickened septation or wall (≥ 5 mm)
cysts
• Cyst contents are viscous material o Vegetations (≥ 5 mm)
• Wall thickness varies from very thin to a few mm in
thickness SELECTED REFERENCES
Microscopic Features 1. Zhao SH et al: MRI in differentiating ovarian borderline
• Cysts are filled with mucinous material
t
from benign mucinous cystadenoma: pathological
• Cysts are lined with single layer of nonatypical mucin-
ne
correlation. J Magn Reson Imaging. 39(1):162-6, 2014
2. Hunter SM et al: Pre-invasive ovarian mucinous tumors are
producing epithelium
characterized by CDKN2A and RAS pathway aberrations.
o Similar to endocervical or intestinal epithelium
•
Clin Cancer Res. 18(19):5267-77, 2012
e.
Ovarian stroma is often very cellular and foci of 3. Thomas RL et al: Bilateral mucinous cystadenomas and
luteinization can occur massive edema of the ovaries in a virilized adolescent girl.
• Rupture of mucinous glands results in granulomas with Obstet Gynecol. 120(2 Pt 2):473-6, 2012
yn
multiple macrophages 4. Aragon L et al: Angiosarcoma of the ovary arising in a
• Papillae are unusual mucinous cystadenoma. J Clin Ultrasound. 39(6):351-5,
• Cyst wall is composed of fibrous stroma

2011
bg
5. Okamoto Y et al: Malignant or borderline mucinous cystic
neoplasms have a larger number of loculi than mucinous
cystadenoma: a retrospective study with MR. J Magn Reson
CLINICAL ISSUES Imaging. 26(1):94-9, 2007
ko
Presentation 6. Ylisaukko-oja SK et al: Germline fumarate hydratase
• Most common signs/symptoms mutations in patients with ovarian mucinous cystadenoma.

Eur J Hum Genet. 14(7):880-3, 2006
o Palpable mass, increasing abdominal girth, and
oo
7. Hart WR: Mucinous tumors of the ovary: a review. Int J

pelvic pain Gynecol Pathol. 24(1):4-25, 2005
• Clinical profile 8. Okada S et al: Calcifications in mucinous and serous cystic
o Symptoms of abdominal or pelvic pressure or ovarian tumors. J Nippon Med Sch. 72(1):29-33, 2005
eb
bloating 9. Chao A et al: Abdominal compartment syndrome secondary

o Acute presentations due to ovarian torsion include to ovarian mucinous cystadenoma. Obstet Gynecol. 104(5
Pt 2):1180-2, 2004
pelvic pain and fever 10. Tanaka YO et al: Functioning ovarian tumors: direct and
o CA125 levels may be mildly elevated
://
indirect findings at MR imaging. Radiographics. 24 Suppl

1:S147-66, 2004
Demographics
• Age
11. Hussain SM et al: MR imaging features of pelvic mucinous
tp
carcinomas. Eur Radiol. 10(6):885-91, 2000

o Can occur at any age but are rare in young women 12. Jeong YY et al: Imaging evaluation of ovarian masses.
ht
and children Radiographics. 20(5):1445-70, 2000

▪ Most common in 3rd to 5th decades 13. Tanaka YO et al: Differential diagnosis of gynaecological
• Epidemiology "stained glass" tumours on MRI. Br J Radiol. 72(856):414-20,
1999
o 20-25% of all benign ovarian neoplasms and 75-85%
14. Brown DL et al: Ovarian masses: can benign and malignant
of all ovarian mucinous tumors lesions be differentiated with color and pulsed Doppler US?
o Increased incidence in Peutz-Jeghers syndrome Radiology. 190(2):333-6, 1994
15. Wagner BJ et al: From the archives of the AFIP. Ovarian
• Excision is curative
epithelial neoplasms: radiologic-pathologic correlation.
Radiographics. 14(6):1351-74; quiz 1375-6, 1994
• Massive tumors can result in abdominal compartment 16. Hendrickson MR et al: Well-differentiated mucinous
syndrome neoplasms of the ovary. Pathology (Phila). 1(2):307-34,
1993
Treatment 17. Young RH et al: Pathology of epithelial tumors. Hematol
• Excision of mucinous cystadenoma Oncol Clin North Am. 6(4):739-60, 1992
• Suspicious peritoneal areas should be biopsied to 18. Buy JN et al: Epithelial tumors of the ovary: CT findings and
correlation with US. Radiology. 178(3):811-8, 1991
exclude peritoneal implants or microinvasion
• Because mucinous cystadenomas are frequently large 19. Ghossain MA et al: Epithelial tumors of the ovary:
comparison of MR and CT findings. Radiology.
when they present, surgery is indicated to exclude
5 malignancy and to prevent torsion
181(3):863-70, 1991
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left pelvic pain shows bilateral
ovarian multilocular cystic
masses . Note the thin regular
septations. (Right) Coronal
bilateral ovarian multilocular
cystic masses . The left
ovarian pedicle appears
stretched and twisted. Surgery
revealed torsion of the left ovary
and pathological examination
confirmed bilateral mucinous
cystadenomas.
t
ne
e.
yn
ultrasound shows a left ovarian
multilocular cystic mass with
bg multiple loculations showing
low-level echoes and variable
echogenicity. (Right) Axial
ko
shows a left ovarian mass .

Two compartments display low
signal intensity and a central
oo
compartment shows high signal

intensity , which may be due
to different concentration of
mucin or intracystic hemorrhage.
eb
://
tp
ht

woman shows an ovarian
cystic mass with a large
peripheral nodular component
containing multiple small
cysts, giving a honeycomb
appearance. (Right) Axial
transvaginal power Doppler
shows blood flow within the solid
component . The presence
of more and smaller loculi
(honeycomb loculi) raises the
possibility of a borderline or
malignant tumor. Pathological
evaluation showed a borderline
mucinous tumor.
5
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a 35-year-old woman
who presented with a
palpable pelvic mass shows a
multilocular left ovarian cystic
mass with thin internal
septations. There is an ill-
defined peripheral area of
lower signal intensity .
the same patient shows the left
ovarian cystic mass with a
peripheral ill-defined area of
lower signal intensity , not
adequately resolved on the
T2W images.
t
ne
e.
yn
the multilocular cystic
ovarian mass . The larger
bg
compartment shows high
pelvic muscles, likely due to
ko
the presence of proteinaceous

material. (Right) Axial T1WI FS
oo
the left ovarian cystic mass

with high signal intensity of
the larger compartment
and an ill-defined peripheral
eb
nodular structure that is

not adequately resolved on the
T1W images.
://
tp
ht

the multilocular cystic left
ovarian mass with thin,
uniform internal septations.
The peripheral nodular
structure is better seen on the
contrast-enhanced images and
represents multiple small cystic
structures separated by
enhancing septations. (Right)
cystic left ovarian mass and
multiple small peripheral cystic
structures separated by
enhancing septations.
5
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Ovary
a palpable adnexal lesion shows
a right ovarian cystic mass
with fine mural calcifications
a multilocular right ovarian
cystic mass with fine septal
calcifications . The presence
of mural calcifications in an
ovarian cystic mass is a good
indicator of mucinous rather than
a serous tumor.
t
ne
e.
yn
with pelvic mass shows a
bg multilocular cystic pelvic mass
with thin septations and no
mural nodules. (Right) Axial
ko
patient shows a multilocular

cystic pelvic mass with thin
septations and no enhancing
oo
nodules. Note the variable T1

signal intensity within the loculi.
eb
://
tp
ht

with a pelvic mass shows a
multilocular cystic pelvic mass
with thin septations and no
mural nodules. Note the shading
in the middle of the image due
to dielectric effect caused by the
shortening of RF wavelengths
inside the body. (Right) Coronal
shows a multilocular cystic pelvic
mass with thin septations and
no mural nodules. Pathological
evaluation revealed a mucinous
cystadenoma.
5
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Ovary ADENOFIBROMA AND CYSTADENOFIBROMA
Key Facts
Terminology o ~ 1/2 are purely cystic; other 1/2 are complex cystic
• Adenofibroma (AF) masses with solid components
o Unilocular or multilocular purely cystic mass, dark
• Cystadenofibroma (CAF)
• Epithelial ovarian neoplasms with dominant fibrous
signal intensity walls on T2WI
o Unilocular or multilocular cystic mass ± solid
stroma
• Termed cystadenofibroma or adenofibroma,
component
o Tiny cystic locules within solid mass are a
depending on relative amount of cystic and solid
characteristic finding → sponge-like appearance on
fibrous tissue components
T2WI
• Bilateral in 12-20% • Unilocular cystic lesions
• AF • Ovarian cystadenocarcinoma
o Solid mass of low signal intensity on T2WI ±
small foci of high signal intensity → sponge-like • Ovarian masses with fibrous components
appearance • Metastatic ovarian tumors
o Solid tumor iso- to hypointense relative to muscles
Clinical Issues
• Frozen section intraoperatively may be useful in
t
on T1WI
•
ne
CAF avoiding unnecessary oophorectomy
e.
yn
a left ovarian multilocular
cystic lesion with relatively
thick hypointense wall and
bg
small solid component ,
also of low signal intensity
relative to muscle. (Right)
ko
Sagittal T2WI MR shows a
multilocular ovarian cystic
mass with a central solid
component of low signal
oo
intensity. Small cystic areas

within the fibrous solid
portion gives the lesion the
eb
characteristic black sponge-like

appearance.
://
tp
ht
(Left) Transvaginal color

a unilocular cystic lesion
with a solid mural nodule
showing blood flow.
(Right) Coronal CECT shows
a multilocular cystic ovarian
mass with thin septations
.
5
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ADENOFIBROMA AND CYSTADENOFIBROMA
Ovary
TERMINOLOGY – This dark signal intensity thickening may
represent a dense fibrous component within the
Abbreviations wall
• Adenofibroma (AF) ▪ Cystic mass with solid component, unilocular or
• Cystadenofibroma (CAF) multilocular
– Solid component similar to AF with sponge-like
Definitions appearance
• Subtype of epithelial ovarian neoplasms in which • DWI
fibrous stroma is a dominant component in addition to o Low signal intensity of solid components on DWI
epithelial elements ▪ Ovarian carcinoma shows high signal intensity on
• Termed CAF or AF depending on relative amount of DWI
cystic and solid fibrous tissue components • T1WI C+
o Solid components with variable enhancement
IMAGING ▪ Usually mild
General Features Ultrasonographic Findings

• Best diagnostic clue • Grayscale ultrasound
o AF o AF
▪ Solid mass of low signal intensity on T2WI ± small ▪ Solid mass, usually hypoechoic relative to
t
myometrium
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foci of high signal intensity
o CAF o CAF
▪ Unilocular or multilocular cystic mass ± solid ▪ Predominantly cystic ovarian mass
component that is similar in appearance to AF – Unilocular anechoic cyst: 13%
e.
• Location – Unilocular cyst with echogenic content: 9%
– Multilocular cyst: 22%
o Bilateral in 12-20%
• – Unilocular complex cyst: 43%
yn
Size
– Multilocular complex cyst: 13%
o Mean diameter: 8 cm
▪ Complex features include septations, papillary
CT Findings projections, or solid nodules
bg
• CECT – Thick or thin septations in 30-67%
– Solid nodules, papillary projections in 56-80%
o AF
▪ Heterogeneously enhancing solid tumor ▪ Wall is usually thin and smooth
ko
▪ Variable enhancement, usually mild – Occasionally thick (> 3 mm) and irregular
o CAF • Color Doppler
▪ Unilocular or multilocular cystic mass with o Blood flow could be detected in 47.8% of cases
oo
septations < 3 mm o Vascularization is usually peripheral, septal, or

– May have papillary projection or solid within solid nodules
component ▪ Sparse scattered vessels
eb
▪ Solid component that is similar in appearance to

AF
MR Findings o US is usually initial modality for evaluating adnexal
://
• T1WI mass
o MR is superior to CT and US for characterization
o AF
▪ Solid tumor iso- to hypointense relative to muscles
tp
o CAF
▪ Solid component similar to AF
ht
▪ Some of the loculated cystic components of Unilocular Cystic Lesions

mucinous CAFs show varied signal intensities • Simple-appearing cysts with uniform thin walls as in
on T1 and T2WI, demonstrating a “stained glass” cystadenomas and functional cysts
appearance • Walls are hairline thin, unlike the relatively thick low
• T2WI signal intensity wall in CAF
o AF
▪ Solid mass shows very low signal intensity on T2WI
Ovarian Cystadenocarcinoma
▪ Tiny cystic locules within the solid mass are a • Multilocular with thick septations, papillary
characteristic finding → sponge-like appearance on projections, diameter > 4 cm
T2WI • Extension beyond ovary not seen with CAF
o CAF: About 1/2 are purely cystic and the other 1/2 are • ADC values in solid portions of carcinoma are
complex cystic masses with solid components significantly lower than those of CAF
▪ Purely cystic CAF, unilocular or multilocular o Cut-off value of 1.20 × 10⁻³ mm²/s for CAF has
– Diffusely or partially thickened, dark signal a sensitivity of 82%, specificity of 93%, positive
intensity walls on T2WI predictive value of 82%, and negative predictive
value of 93%
5
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Ovarian Masses With Fibrous Components o Peak incidence in 4th & 5th decades
• Includes fibroma, fibrothecoma, and Brenner tumor o Range: 15-65 years
o Occurs almost evenly in pre- and postmenopausal
o Small Brenner tumors usually manifest as solid
masses women
• As with AF, fibrous component demonstrates low signal Natural History & Prognosis
intensity on T2WI • Good: Benign
• Extensive amorphous calcification is often present
within solid component on CT Treatment
o Calcifications are not a prominent feature of AF or • Patients undergo surgical removal
CAF • Frozen section intraoperatively may be useful in
avoiding unnecessary oophorectomy
Metastatic Ovarian Tumors
• Specifically metastases with a highly fibrous
component DIAGNOSTIC CHECKLIST
o Most often from a gastrointestinal tract primary
tumor Image Interpretation Pearls
• Often demonstrate hypointense solid components on • Low T2 signal intensity of cyst wall or solid portion
T2WI with strong enhancement on MR is the key to differentiate CAF from ovarian
carcinoma
•
t
Vascularized or solid enhancing component may
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PATHOLOGY suggest malignancy
• Cystic and solid elements SELECTED REFERENCES
e.
• Lining may be flat or have focal papillary projections 1. Takeuchi M et al: Ovarian adenofibromas and
• Cut surface may demonstrate a yellowish fibrous cystadenofibromas: magnetic resonance imaging findings
yn
nodule protruding into cystic lumen including diffusion-weighted imaging. Acta Radiol.
54(2):231-6, 2013
Microscopic Features 2. Tang YZ et al: The MRI features of histologically proven
• Differs from cystadenoma due to presence of ovarian cystadenofibromas-an assessment of the
bg
prominent fibrous tissue component in addition to morphological and enhancement patterns. Eur Radiol.
epithelial elements 23(1):48-56, 2013
• Glandular structures scattered within dense fibrous 3. Khashper A et al: T2-hypointense adnexal lesions: an
ko
imaging algorithm. Radiographics. 32(4):1047-64, 2012
tissue
•
4. Li W et al: Diffusion-weighted MRI: a useful technique
Purely cystic lesions on imaging have small foci of to discriminate benign versus malignant ovarian surface
fibrous stroma detected only microscopically epithelial tumors with solid and cystic components. Abdom
•
oo
Classified according to epithelial cell types into Imaging. 37(5):897-903, 2012

o Serous (most common) 5. Takeuchi M et al: Diffusion-weighted magnetic resonance
o Endometrioid imaging of ovarian tumors: differentiation of benign and
o Mucinous
eb
malignant solid components of ovarian masses. J Comput

o Clear cell Assist Tomogr. 34(2):173-6, 2010
6. Fujii S et al: Diagnostic accuracy of diffusion-weighted
o Mixed
•
imaging in differentiating benign from malignant ovarian
://
Degree of epithelial proliferation/atypia and its relation lesions. J Magn Reson Imaging. 28(5):1149-56, 2008
to stromal component is used to classify lesions 7. Jung DC et al: MR imaging findings of ovarian
o Benign: No cytological atypia or stromal invasion cystadenofibroma and cystadenocarcinofibroma: clues for
tp
o Borderline: Cytological atypia, no stromal invasion the differential diagnosis. Korean J Radiol. 7(3):199-204,
o Malignant (cystadenocarcinofibroma): Cytological 2006
8. Cho SM et al: CT and MRI findings of cystadenofibromas of
ht
atypia and stromal invasion

the ovary. Eur Radiol. 14(5):798-804, 2004
9. Kim KA et al: Benign ovarian tumors with solid and cystic
CLINICAL ISSUES components that mimic malignancy. AJR Am J Roentgenol.
182(5):1259-65, 2004
Presentation 10. Takeuchi M et al: Ovarian cystadenofibromas: characteristic
• Most common signs/symptoms magnetic resonance findings with pathologic correlation. J
Comput Assist Tomogr. 27(6):871-3, 2003
o Usually asymptomatic and incidentally found on
11. Jung SE et al: CT and MR imaging of ovarian tumors
imaging
•
with emphasis on differential diagnosis. Radiographics.
Other signs/symptoms 22(6):1305-25, 2002
o Palpable mass 12. Alcazar JL et al: Sonographic features of ovarian
o Abdominal distension cystadenofibromas: spectrum of findings. J Ultrasound Med.
o Vague gastrointestinal symptoms 20(8):915-9, 2001
o May present with acute pain if causing ovarian 13. Fatum M et al: Papillary serous cystadenofibroma of the
ovary--is it really so rare? Int J Gynaecol Obstet. 75(1):85-6,
torsion 2001
o Hormonal activity rare
14. Outwater EK et al: Ovarian fibromas and cystadenofibromas:
Demographics MRI features of the fibrous component. J Magn Reson
5 • Age Imaging. 7(3):465-71, 1997
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small right ovarian mass .
The mass demonstrates very
low T2 signal intensity with
small foci of high T2 signal ,
resulting in the characteristic
sponge-like appearance. (Right)
same patient shows minimal
enhancement of the ovarian
mass , significantly less than
the degree of enhancement of
the myometrium.
t
ne
e.
yn
replacement of the left ovary
by a solid low signal intensity
bg mass containing multiple
small T2 high signal intensity
cystic spaces. The solid mass
is also surrounded by multiple
ko
different-sized cysts . (Right)

Coronal T2WI MR in the same
patient shows similar appearance
oo
of the right ovary with solid

low signal intensity mass
containing small cystic loculi and
surrounded by multiple cysts .
eb
://
tp
ht

same patient shows enlarged
ovaries with central low
signal intensity masses containing
small cystic locules & surrounded
by multiple cysts. (Right) Axial
patient shows mild enhancement
of the solid components and
no significant enhancement of
the walls of the surrounding cysts
.
5
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Obgyne Books Full

ultrasound shows a
heterogeneous left adnexal
mass . The mass is
predominantly hypoechoic
with areas of internal increased
echogenicity. (Right) Sagittal
transvaginal color Doppler
ultrasound shows the left
adnexal mass to be vascular
with increased flow at the
periphery.
t
ne
e.
yn
left adnexal mass separate
from the uterus and arising
from the left ovary . The
bg
mass is isointense to skeletal
muscles on T1WI. (Right) Axial
ko
shows the left ovarian mass

demonstrating very low signal
intensity with small central
oo
area of high signal intensity

.
eb
://
tp
ht

a low signal intensity left
ovarian mass . (Right)
slightly enhancing left ovarian
mass . The degree of
enhancement is less than
that of the myometrium. The
mass was found to be serous
adenofibroma on histological
examination.
5
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Ovary
a multilocular left ovarian
cystic mass . The mass is
predominantly hypointense to
muscle. The wall is difficult to
discern from the cysts' contents.
One of the cysts shows
relatively high T1 signal intensity.
(Right) Axial T2WI MR shows a
complex left ovarian multilocular
cystic structure . The lesion
has a relatively thick wall
that displays very low signal
intensity on T2WI. The wall
is otherwise smooth with no
papillary projections or solid
t
masses.
ne
e.
yn
old woman shows a left ovarian
bg internal septation dividing the
mass into locules. The septa
are thin, < 3 mm in thickness.
ko
same patient shows a left ovarian

multilocular cystic mass . The
appearance is indistinguishable
oo
from cystadenomas,
particularly mucinous
cystadenoma. Pathological
examination revealed serous
eb
cystadenofibroma.
://
tp
ht

ultrasound shows a complex
multilocular left ovarian mass
with solid mural nodules
. The larger locule contains
floating low-level echoes, a
finding that is common in
mucinous ovarian neoplasms.
(Right) Axial transvaginal color
Doppler ultrasound in the same
patient shows flow within the
septa separating the cystic
components. This was found to
be mucinous cystadenofibroma
on histological examination.
5
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Ovary OVARIAN SEROUS CARCINOMA
Key Facts
Terminology • Mucinous cystadenocarcinoma of ovary
• Classified as malignant ovarian epithelial tumor • Ovarian metastasis
Imaging Pathology
• Most often seen as complex cystic masses with solid/ • Staged according to TNM and FIGO staging systems
papillary components arising from ovary
Clinical Issues
• Bilateral in majority of cases • ↑ CA125 in majority of cases of ovarian serous
• Low-grade serous carcinoma (LGSC) carcinoma
o Predominantly cystic masses with septations and o Not recommended for initial screening due to lack of
papillary solid components
•
sensitivity and specificity
High-grade serous carcinoma (HGSC)
o Complex cystic mass with large solid components
• Predominantly perimenopausal and postmenopausal
women
o May also appear entirely solid
• ~ 60% of all ovarian malignant tumors
• MR is superior to US and CT in tumor characterization
• 5-year survival rate
due to better soft tissue resolution o LGSC: ~ 40–56%
Top Differential Diagnoses o HGSC: ~ 10–20%
•
t
• Benign serous or mucinous cystadenoma of ovary Treatment: Cytoreductive (tumor-debulking) surgery
ne
e.
yn
(Left) Axial transvaginal color
a large, almost completely
solid pelvic mass with
bg
increased vascularity. (Right)
Axial transvaginal color
ko
predominantly cystic ovarian
mass with a peripheral
solid component showing
increased vascularity. Ovarian
oo
serous carcinoma appears as

a complex cystic mass with
mural nodules or as a solid
eb
mass.
://
tp
ht

multilocular cystic left ovarian
mass with a prominent
and large volume ascites
shows bilateral ovarian masses
with prominent solid
components demonstrating
to pelvic skeletal muscles
and very high signal cystic
components . Both high-
and low-grade ovarian serous
carcinomas are frequently
bilateral.
5
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OVARIAN SEROUS CARCINOMA
Ovary
o May appear as an entirely solid mass
TERMINOLOGY
• Color Doppler
Abbreviations o Solid components demonstrate vascularity
• Low-grade serous carcinoma (LGSC) Nuclear Medicine Findings
• High-grade serous carcinoma (HGSC) • PET
Definitions o Increased metabolic activity
• Classified as malignant ovarian epithelial tumor Imaging Recommendations
IMAGING o US is most commonly used method to detect and
characterize adnexal mass
General Features o MR is superior to US and CT in tumor
• Best diagnostic clue characterization due to better soft tissue resolution
o Most often seen as complex cystic masses with solid/ o CT is most often used in advanced disease to assess
papillary components arising from ovary peritoneal carcinomatosis or distant metastases
• Location
o LGSC
▪ Bilateral in 74–77% of cases DIFFERENTIAL DIAGNOSIS
o HGSC
t
Benign Serous or Mucinous Cystadenoma of
▪ Bilateral in 84% of cases
ne
Ovary
• Size
• Often < 4 cm in size
o Varies but may present as large masses
• • Entirely cystic
e.
• Wall thickness < 3 mm
Morphology
o LGSC
▪ Predominantly cystic masses with septations and • Absence of ascites, peritoneal disease, or
yn
papillary solid components lymphadenopathy
o HGSC Mucinous Cystadenocarcinoma of Ovary
▪ Complex cystic mass with large solid components • Tend to be larger and multiloculated
bg
▪ May also appear entirely solid
• Often variable echogenicity (US), density (CT), or
CT Findings signal intensity (MR) owing to mucinous contents of
• NECT cystic components
ko
o Low attenuation cystic mass with soft tissue Ovarian Metastasis

attenuation solid components
o Although psammoma bodies (microscopic
• Most ovarian metastases are solid or mixture of solid
oo
and cystic tumors

calcifications) are present in 30% of histologic
specimens, they are detected in only 12% of cases
• Clinical presentation often due to primary disease
with CT
•
eb
CECT PATHOLOGY
o Low attenuation cystic mass with enhancing solid
General Features
components
• Etiology
://
o Contrast enhancement helps to differentiate blood

o New histopathological, molecular, and genetic
clot, which does not enhance, from enhancing solid
studies have provided a better model for ovarian
tp
components of tumor
carcinogenesis, showing 2 broad categories
MR Findings ▪ Type I (LGSC)
• T1WI – Much less common than HGSC
ht
o Low to intermediate signal intensity cystic mass with – Evolve in a stepwise fashion from benign serous
intermediate intensity solid components cystadenoma to serous borderline tumors and
• T2WI finally to LGSC
– Indolent behavior
o High signal intensity cystic mass with heterogeneous
signal intensity solid components – Often confined to ovary at time of diagnosis
• T1WI C+ – Stable genome and without TP53 mutations
▪ Type II (HGSC)
o Solid components of mass demonstrate marked
enhancement – Likely originate from epithelium of fimbrial
o Contrast enhancement helps to differentiate blood portion of fallopian tube
clot, which does not enhance, from enhancing mural – More aggressive
nodules – Often found at advanced stage
– Genetically highly unstable; majority have TP53
Ultrasonographic Findings mutations
• Grayscale ultrasound – Association with BRCA1 and BRCA2 genes
o Cystic adnexal mass containing different echogenic
Staging, Grading, & Classification
patterns, thick walls, septations, nodules, or papillary
• Staged according to TNM and FIGO staging systems
projections
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Gross Pathologic & Surgical Features o Histologic type, grade, and stage of disease
• Most often unilocular or septated cystic masses with ▪ 5-year survival rates: 80-90% for early stages and
15-20% for advanced stages
papillary solid projections
o Prognosis for patients with advanced disease is
Microscopic Features directly related to success of cytoreductive surgery
• Epithelium that characterizes serous tumors resembles • LGSC
lining of fallopian tube o Behaves like a slow-growing indolent neoplasm
• Papillary, glandular, and solid patterns of growth on (presumably due to lack of TP53 mutations) and has a
histological analysis better prognosis
• Tumor usually contains glands, solid sheets of cells, or o Lower response rate to platinum-based neoadjuvant
slit-like spaces chemotherapy
• Tumor cells often diffusely infiltrate fibrous stroma o Up to 30% of LGSCs may recur
• Laminated psammoma bodies are usually present ▪ Recurrent tumors are often chemoresistant
• Features that help distinguish serous o 5-year survival rate is ~ 40–56%
cystadenocarcinomas from borderline serous tumors • HGSC
include o Biologically aggressive neoplasms that often present
o Obvious stromal invasion at an advanced stage
o Extensive cellular budding and confluent cellular ▪ Up to 85% of patients present with widespread
growth peritoneal metastases
t
o Nuclear atypia o Better response rate to platinum-based neoadjuvant
ne
chemotherapy
o 5-year survival rate of 10–20%
CLINICAL ISSUES
e.
Presentation Treatment
• Most common signs/symptoms • Cytoreductive (tumor-debulking) surgery
o To reduce maximum diameter of remaining implants
yn
o Pelvic mass
o Pelvic pain to < 1 cm
o Abdominal swelling due to ovarian enlargement or •
bg Neoadjuvant chemotherapy
ascites
• Other signs/symptoms DIAGNOSTIC CHECKLIST
o Anemia, cachexia
o ↑ CA125 in majority of cases of ovarian serous Consider
ko
carcinoma • Bilaterality and peritoneal carcinomatosis is seen

▪ 80% have CA125 levels > 35 U/mL more frequently in serous than in mucinous
– 50% in stage I disease cystadenocarcinomas
oo
– 90% in stage II
– > 90% in stages III and IV SELECTED REFERENCES
▪ Not recommended for initial screening
eb
– Due to the lack of sensitivity and specificity 1. Chung HH et al: Preoperative [F]FDG PET/CT predicts
recurrence in patients with epithelial ovarian cancer. J
▪ Widely accepted as an adjunct in distinguishing
Gynecol Oncol. 23(1):28-34, 2012
benign from malignant disease 2. Lalwani N et al: Histologic, molecular, and cytogenetic
://
– Particularly in postmenopausal women features of ovarian cancers: implications for diagnosis and
presenting with ovarian masses treatment. Radiographics. 31(3):625-46, 2011
▪ Useful postoperatively in predicting likelihood that
tp
3. Shin JE et al: The serum CA-125 concentration data assists

tumor would be found at a 2nd-look operation in evaluating CT imaging information when used to
▪ Serial measurement of CA125 may also play a role differentiate borderline ovarian tumor from malignant
ht
epithelial ovarian tumors. Korean J Radiol. 12(4):456-62,

in monitoring response to chemotherapy
2011
Demographics 4. Acs G: Serous and mucinous borderline (low malignant
• Age potential) tumors of the ovary. Am J Clin Pathol. 123
Suppl:S13-57, 2005
o Predominantly perimenopausal and postmenopausal
5. Dexeus S et al: Conservative management of epithelial
women ovarian cancer. Eur J Gynaecol Oncol. 26(5):473-8, 2005
o LGSC 6. Rabban JT et al: Current issues in the pathology of ovarian
▪ Mean age at presentation is 62.6 years cancer. J Reprod Med. 50(6):467-74, 2005
o HGSC 7. Sohaib SA et al: The role of magnetic resonance imaging and
▪ Mean age at presentation is 55.5 years ultrasound in patients with adnexal masses. Clin Radiol.
• Epidemiology
8.
60(3):340-8, 2005
Jung SE et al: CT and MR imaging of ovarian tumors
o Ovarian serous carcinomas account for ~ 60% of all
ovarian malignant tumors 22(6):1305-25, 2002
▪ HGSCs constitute 90% of all serous carcinomas
▪ LGSCs constitute 10% of all serous carcinomas
5
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Ovary
year-old woman who had
a known simple left ovarian
cystic mass for 9 years shows
a multilocular cystic lesion
with a peripheral nodule of
intermediate signal intensity .
There is small amount of free
pelvic fluid . (Right) Sagittal
shows a nodule of intermediate
signal intensity and small
amount of free fluid within
the cul-de-sac.
t
ne
e.
yn
patient shows the hypointense
cystic lesion and peripheral
bg area of intermediate signal
intensity relative to pelvic
skeletal muscles. (Right) Axial
ko
shows the cystic pelvic mass

demonstrating low signal
intensity, and a peripheral nodule
oo
of slightly increased signal

intensity relative to skeletal
muscles.
eb
://
tp
ht

of the peripheral soft tissue
nodule . Fluid in the cul-de-
sac shows a fluid level with
dependent high signal intensity
fluid likely due to hemorrhage
or proteinaceous material.
the enhancing peripheral soft
tissue nodule . Pathological
evaluation revealed low-grade
ovarian cystadenocarcinoma,
presumably arising in a benign
cystadenoma.
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presented with palpable pelvic
mass shows a large infiltrative
mass almost completely
filling the pelvis. The mass is
hyperintense relative to pelvic
skeletal muscles. There is an
enlarged pelvic sidewall lymph
node . (Right) Sagittal T2WI
a large mass filling the
pelvic cavity.
t
ne
e.
yn
pelvic mass demonstrating
low signal intensity relative to
bg
the pelvic skeletal muscles.
ko

large pelvic mass . The
mass extends posteriorly to
oo
the sacrum . Pathological

examination revealed ovarian
high-grade serous carcinoma.
eb
://
tp
ht

of breast cancer who tested
positive for BRCA1 gene shows
a right ovarian mass that
is predominantly solid with
a cystic component and
a small focus of calcification
. The mass invades into the
uterus . (Right) Coronal
shows a right ovarian mass
as well as a left ovarian
mass . There is perihepatic
ascites . Bilateral ovarian
involvement was confirmed
during surgery, which revealed
high-grade ovarian carcinoma.
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Ovary
with pelvic masses shows
bilateral ovarian masses
with mixed solid and cystic
components. (Right) Sagittal
shows the mixed solid and cystic
right ovarian mass with
invasion into the myometrium
. Cystic peritoneal metastases
are also seen .
t
ne
e.
yn
patient shows a large pelvic
mass . The mass shows low
bg signal intensity relative to the
pelvic skeletal muscles. It is very
difficult on T1WI to separate the
individual masses from normal
ko
pelvic structures. (Right) Axial

patient shows bilateral ovarian
oo
masses with significant

of the solid components.
Pathological evaluation revealed
eb
bilateral high-grade serous

carcinoma.
://
tp
ht

an enlarging abdomen shows
bilateral multilocular cystic
ovarian masses , larger on
the right side, with enhancing
solid mural nodules . Also
note the omental nodularities
due to peritoneal metastatic
disease. (Right) Coronal CECT in
ovarian cystic masses with
prominent mural nodularities
. Pathological evaluation
revealed bilateral low-grade
serous carcinoma.
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Ovary MUCINOUS CYSTADENOCARCINOMA
Key Facts
• Classified as malignant epithelial ovarian neoplasm • Origin of these tumors is unknown
Imaging • Staged as other ovarian carcinomas using FIGO and
TNM staging systems
• Multilocular cystic ovarian mass with variable imaging • Size and laterality are important in distinguishing
appearance of cystic components depending on mucin primary ovarian mucinous carcinoma from metastases
content
• Nodules or solid components are seen associated with Clinical Issues
a multilocular cystic mass • Pelvic mass and pain
• Almost always unilateral • Predominantly perimenopausal and postmenopausal
• Often large masses; 6-40 cm women
• Thick septa and solid mural nodules demonstrate • Only 3–4% of ovarian carcinomas
enhancement • Most are stage I at presentation
Top Differential Diagnoses • Treated with cytoreductive (tumor-debulking) surgery
• Benign serous or mucinous cystadenoma of ovary • Patients with advanced-stage primary mucinous
• Serous adenocarcinoma of ovary
carcinomas have significantly shorter overall survival
t
compared to patients with advanced-stage serous
• Ovarian metastasis
ne
carcinoma
e.
yn
pelvic mass composed of
numerous small cystic spaces
bg
separated by thick septa
(honeycomb appearance).
(Right) Axial transabdominal
ko
color Doppler ultrasound in
the same patient shows a large
pelvic mass with internal
blood flow. The smaller and
oo
more numerous the loculi, the

more likely a mucinous tumor
is borderline or malignant and
eb
not benign.
://
tp
ht

large multilocular cystic mass
with areas of enhancing
solid soft tissue component
and thick irregular septations
. (Right) Sagittal T2WI MR
shows an ovarian multilocular
cystic mass with numerous
variable-sized loculi. The septa
are thin and there are no mural
nodules.
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MUCINOUS CYSTADENOCARCINOMA
Ovary
o Increased metabolic activity within solid
TERMINOLOGY
components
Synonyms
• Mucinous carcinoma • Best imaging tool
Definitions o US is method of choice for initial characterization
• Classified as malignant epithelial ovarian neoplasm o MR may be used in cases when US is equivocal
o CT is reserved for staging if malignancy is being
considered
IMAGING
General Features DIFFERENTIAL DIAGNOSIS
• Best diagnostic clue Benign Serous or Mucinous Cystadenoma of
o Multilocular cystic ovarian mass with variable
imaging appearance of cystic components depending Ovary
on mucin content • Often < 4 cm in size
o Nodules or solid components are seen associated • Entirely cystic
with a multilocular cystic mass • Wall thickness < 3 mm
• Location • The smaller and more numerous the loculi, the more
o Almost always unilateral
t
likely a mucinous tumor is borderline or malignant and
•
ne
Size not benign
o Often large masses; 13-40 cm • Absence of ascites, peritoneal disease, or
• Morphology lymphadenopathy
o Large, multilocular cystic tumors with solid mural
e.
Serous Adenocarcinoma of Ovary
nodules
• More common than mucinous adenocarcinoma
CT Findings • Mixed cystic and solid mass with papillary projections
yn
• NECT • Psammoma bodies may be present
o Multiseptated, low-attenuation cystic masses
o High attenuation may be seen in some loculi due to Ovarian Metastasis
bg
high protein content of mucinous material • Most ovarian metastases are solid or a mixture of solid
• CECT and cystic tumors
o Low-attenuation, multiloculated, cystic mass • Clinical presentation is often due to primary disease
ko
o Thick septa and solid mural nodules demonstrate • Ovarian lesions are often bilateral and < 13 cm in size
enhancement
oo
MR Findings PATHOLOGY
• T1WI
General Features
o Signal intensity varies depending on degree of mucin
• Etiology
eb
concentration of cystic components of mass o Benign, borderline, noninvasive carcinoma, and

o Loculi with watery mucin have lower signal intensity
invasive components may coexist within an
than loculi with thicker mucin
• individual tumor
://
T2WI
▪ Suggests stepwise manner of progression from
o Signal intensity varies depending on degree of mucin
preexisting mucinous cystadenoma and mucinous
concentration of cystic components of mass
tp
borderline tumor
o Loculi with watery mucin have high signal intensity
and loculi with thicker mucin have lower signal Staging, Grading, & Classification
• Staged as other ovarian carcinomas using FIGO and
ht
intensity
o Solid mural nodules demonstrate intermediate signal TNM staging systems
intensity
• T1WI C+
• Size and laterality are important in distinguishing
o Thick septa and solid mural nodules demonstrate
primary ovarian mucinous carcinoma from metastases
enhancement o All bilateral mucinous carcinomas of ovary and all
Ultrasonographic Findings unilateral carcinomas < 13 cm are most likely to be
• Grayscale ultrasound metastatic
o Multiloculated cystic mass containing different • Large, multilocular cystic masses that contain
echogenic patterns in cystic components gelatinous material
o Solid mural nodules can be seen within cystic
•
components
Color Doppler
• Cells of mucinous carcinomas may resemble those of
gastric pylorus, intestine, or endocervix
o Solid components demonstrate vascularity o Vast majority show gastrointestinal differentiation
Nuclear Medicine Findings • Benign, borderline (cytological atypia, no stromal
• PET invasion), and invasive carcinoma (stromal invasion)
may be seen in different areas of same tumor
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• Tumor is composed of glands, cribriform patterns, and SELECTED REFERENCES

solid sheets
• Less intracytoplasmic mucin content seen in higher 1. Zhao SH et al: MRI in differentiating ovarian borderline
from benign mucinous cystadenoma: pathological
histologic grades
• Immunohistochemistry may help to distinguish 2.
correlation. J Magn Reson Imaging. 39(1):162-6, 2014
Soslow RA: Mucinous ovarian carcinoma: slippery business.
primary ovarian mucinous tumor from metastatic Cancer. 117(3):451-3, 2011
colorectal adenocarcinoma 3. Zaino RJ et al: Advanced stage mucinous adenocarcinoma
o Ovarian mucinous cystadenocarcinomas are usually of the ovary is both rare and highly lethal: a Gynecologic
positive for CK7 and CK20 (reaction is typically weak Oncology Group study. Cancer. 117(3):554-62, 2011
and focal) 4. Okamoto Y et al: Malignant or borderline mucinous cystic
o Colorectal carcinoma is negative for CK7, positive for neoplasms have a larger number of loculi than mucinous
cystadenoma: a retrospective study with MR. J Magn Reson
CK20
Imaging. 26(1):94-9, 2007
5. Kikkawa F et al: Clinical characteristics and prognosis of
CLINICAL ISSUES mucinous tumors of the ovary. Gynecol Oncol. 2006
6. Togashi K. Related Articles et al: Ovarian cancer: the clinical
Presentation role of US, CT, and MRI. Eur Radiol. 13 Suppl 4:L87-104,
• Most common signs/symptoms 7.
2003
Jung SE et al: CT and MR imaging of ovarian tumors
o Pelvic mass
o Pelvic pain
t
22(6):1305-25, 2002
o Abdominal swelling due to ovarian enlargement or
ne
8. Rodriguez IM et al: Mucinous tumors of the ovary: a
ascites clinicopathologic analysis of 75 borderline tumors
• Other signs/symptoms (of intestinal type) and carcinomas. Am J Surg Pathol.
o Anemia, cachexia 26(2):139-52, 2002
e.
9. Jeong YY et al: Imaging evaluation of ovarian masses.
Demographics Radiographics. 20(5):1445-70, 2000
• Age 10. Lee KR et al: Mucinous tumors of the ovary: a
yn
o Predominantly perimenopausal and postmenopausal clinicopathologic study of 196 borderline tumors (of
intestinal type) and carcinomas, including an evaluation of
women
•
11 cases with 'pseudomyxoma peritonei'. Am J Surg Pathol.
Epidemiology
bg 24(11):1447-64, 2000
o Only 3–4% of ovarian carcinomas are of mucinous 11. Ozols RF et al: Epithelial ovarian cancer. In: Hoskins WJ
type et al: Principles and practice of gynecologic oncology.
Philadelphia: Lippincott Williams & Wilkins. 981-1057,
ko
Natural History & Prognosis 2000

• Most important prognostic factors 12. Zissin R et al: Synchronous mucinous tumors of the
o Histologic type, grade, and stage of disease ovary and the appendix associated with pseudomyxoma
oo
o Prognosis for patients with advanced disease is peritonei: CT findings. Abdom Imaging. 25(3):311-6, 2000
13. Kawamoto S et al: CT of epithelial ovarian tumors.
directly related to success of cytoreductive surgery
•
Radiographics. 19 Spec No:S85-102; quiz S263-4, 1999
Most cases are stage I at presentation
•
eb
Patients with advanced-stage primary mucinous

carcinomas have significantly shorter overall survival
compared to patients with advanced-stage serous
://
carcinoma
o Estimated median survival of only of 14 months
compared to 42 months
tp
Treatment
• Cytoreductive (tumor-debulking) surgery
ht
o To reduce maximum diameter of remaining implants

to < 1 cm
• Neoadjuvant chemotherapy
o Preoperative &/or after surgery
• Mucinous cystadenocarcinoma of ovary should be
considered in presence of
o Multilocular cystic adnexal mass with variable
appearance of cystic components on imaging studies
due to variable mucin content of cystic components
o Tumor > 13 cm
o Unilateral tumor
5
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Ovary
bilocular cystic ovarian mass
. The 2 loculi show slightly
different echogenicity. The
patient declined surgery and was
lost to follow-up. (Right) Axial
the same patient 10 years later
shows an ovarian mass with
significantly increased number
of loculi and solid components
revealed malignant ovarian
cystadenocarcinoma.
t
ne
e.
yn
with palpable abdominal mass
bg shows a large multilocular cystic
mass filling the pelvis. The
mass also contains a large soft
tissue enhancing component
ko

(18 cm) multilocular cystic mass
oo
with areas of enhancing

solid soft tissue component
eb
cystadenocarcinoma.
://
tp
ht

with a palpable abdominal
mass shows a large multilocular
cystic mass filling the
pelvis. The mass contains ill-
defined areas of enhancement
with irregular thick septa .A
moderate amount of ascites is
present. Pathological evaluation
cystadenocarcinoma.
5
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presented with a palpable
mass shows a right ovarian
multilocular cystic mass .
The loculi show different
T2 signal intensities. There
is a left ovarian unilocular
cystic lesion with a thin
wall and no mural nodules.
mass with variable T2
signal intensities. There are
numerous variably sized loculi.
t
The septa are thin, and there
ne
are no mural nodules.
e.
yn
same patient shows a right
mass with variable T1
bg
signal intensities, reflecting
different mucin concentration
or intracystic hemorrhage. The
ko
left ovarian cystic lesion

shows fluid signal intensity.
oo

mass with loculi of high
signal intensity .
eb
://
tp
ht

mass with an enhancing
wall and septa. (Right) Sagittal
patient shows a right ovarian
with enhancing wall and
septa. Although the septa
were thin and there were no
enhancing soft tissue nodules,
the possibility of mucinous
cystadenocarcinoma was
raised based on the presence
of numerous loculi and was
confirmed at surgery.
5
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Ovary
a palpable abdominal mass
shows a large multilocular cystic
mass filling the pelvis. The
mass also contains a large soft
tissue enhancing component
unilateral multilocular cystic
mass with areas of enhancing
solid soft tissue component .
Note also peritoneal metastatic
nodules . Pathological
evaluation revealed malignant
ovarian cystadenocarcinoma.
t
ne
e.
yn
woman who presented with a
palpable abdominal mass shows
bg a large unilateral multilocular
cystic mass . No significant
soft tissue component was noted,
and the septations were thin and
ko
uniform. (Right) Coronal CECT

in the same patient shows a large
unilateral multilocular cystic
oo
mass without solid soft tissue

component. This was thought
to represent a benign mucinous
cystadenoma, but pathological
eb
evaluation revealed malignant

cystadenocarcinoma.
://
tp
ht

ultrasound in a 52-year-
with pelvic fullness shows a
containing low-level internal
echoes and a polypoid soft
tissue component . (Right)
Axial transvaginal color Doppler
shows a multilocular cystic mass
with areas of polypoid soft
tissue components showing
internal blood flow.
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Ovary OVARIAN ENDOMETRIOID CARCINOMA
Key Facts
Terminology • Mucinous cystadenoma/carcinoma
• Classified as a malignant ovarian epithelial tumor • Clear cell carcinoma
Imaging
• Endometrioma
• When arising de novo Pathology
o Large, complex, multilocular cystic mass with soft • Associated abnormalities
tissue components o Endometrial hyperplasia or carcinoma
• When arising in an endometrioma o Lynch syndrome
o Endometriosis
o Enhancing mural nodules appear to be the most
valuable imaging finding to suggest a coexisting • High incidence of concomitant synchronous
carcinoma endometrial carcinoma representing a 2nd primary
• 30% are bilateral tumor rather than metastatic disease
• T2 shading, a characteristic feature of endometriomas, Clinical Issues
may not be present in an endometrioma with
• 2nd most common ovarian cancer
• Up to 42% of patients have endometriosis
t
• Serous cystadenoma/carcinoma
ne
e.
yn
mass with large peripheral
bg
solid components . The cyst
is filled with homogeneous
fluid with low-level echoes.
ko
The solid component is of
heterogeneous echogenicity.
duplex Doppler ultrasound
oo

blood flow within the
solid component. Spectral
eb
analysis of blood flow shows

low impedance due to
neovascularity.
://
tp
ht

ultrasound shows a
mass with homogeneous
low-level echoes. Multiple
mural nodules are seen
within the cyst. (Right) Sagittal
shows blood flow within 1
of the mural nodules .
This was confirmed as an
endometrioid carcinoma
during surgery. It should
be noted that benign mural
nodules may be present within
endometriomas, and these can
even enhance on CECT and
5 MR.
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OVARIAN ENDOMETRIOID CARCINOMA
Ovary
TERMINOLOGY ▪ Intermediate or heterogeneous signal solid
components
Definitions o Arising in an endometriotic cyst
• Classified as a malignant ovarian epithelial tumor ▪ Intermediate or high-signal nodule in an otherwise
intermediate signal intensity mass
▪ T2 shading, a characteristic feature of
IMAGING endometriomas, may not be present in an
General Features endometrioma with malignant transformation
• Best diagnostic clue – May be due to dilution of hemorrhagic
contents by nonhemorrhagic fluid produced by
o When arising de novo
malignant tumor
▪ Indistinguishable from other histologic subtypes of
ovarian epithelial carcinoma • T1WI C+ FS
o Solid components show marked enhancement
– Large, complex, multilocular cystic mass with
soft tissue components Ultrasonographic Findings
▪ Synchronous endometrial thickening may be due • Grayscale ultrasound
to hyperplasia or carcinoma o Arising de novo
o May also arise within an endometrioma ▪ Mixed solid and cystic ovarian mass
▪ Best imaging clues of malignancy in an ▪ Predominantly solid mass with areas of
t
endometrioma hemorrhage or necrosis
ne
– Enhancing mural nodule (most sensitive) o Arising in endometriotic cyst
– Loss (absence) of T2 shading in endometriotic ▪ Cystic lesion with sonographic features of
cyst endometrioma also demonstrating mural nodules
– Mural nodule diameter > 3 cm
•
e.
Color Doppler
– Interval increase in size of cyst o Vascularity demonstrated in solid components
• Location
yn
o 30% are bilateral Imaging Recommendations
• Morphology • Best imaging tool
o When arising de novo o Transvaginal ultrasound (TVUS) is initial modality of
bg
▪ Mixed solid and multilocular cystic mass choice: Demonstrates cystic and solid nature of mass
▪ More often predominantly solid than other o MR is a problem-solving modality in cases of
epithelial malignancies indeterminate adnexal mass on TVUS
o CT of abdomen and pelvis is most often used for
ko
o Solid nodule developing within endometrioma or
area of endometriosis preoperative staging and follow-up
▪ Larger cyst size (> 10 cm) seems to be a risk factor • Protocol advice
o Color Doppler and contrast-enhanced images
oo
for malignancy
▪ Significant enlargement of an endometrioma differentiate tumoral tissue from blood clot/debris
on serial follow up may also be suspicious for
eb
malignancy
CT Findings
• Enhancing solid components and mural nodules Serous Cystadenoma/Carcinoma
• Most commonly presents as cystic mass with papillary
://
o Allows differentiation from blood clot or debris

• Low attenuation cystic mass
projections
• Calcified psammoma bodies may be detected by CT
tp
MR Findings
Mucinous Cystadenoma/Carcinoma
• T1WI • Large, multiloculated cystic mass
o Arising de novo
ht
▪ Mixed solid and cystic mass • "Marble" appearance due to variable mucin content
within locules
– Low to intermediate signal intensity cystic
component Clear Cell Carcinoma
– Intermediate signal solid components
o Arising in an endometriotic cyst
• 45-49% associated with endometriosis
o May develop from endometrioma
▪ Low- or intermediate-signal nodule in an otherwise • Mixed solid/cystic mass
high-signal endometrioma
▪ High-signal endometriotic foci may be seen in cul-
• No definite imaging criteria to differentiate from other
epithelial neoplasms
de-sac or along utero-sacral ligaments
• T1WI FS Endometrioma
o Endometriotic cyst remains high signal intensity, • Uniform high SI on T1WI
confirming presence of blood products rather than • Low SI on T2WI: Shading
fat • Absence of enhancing soft tissue nodule
• T2WI
o Arising de novo
▪ High signal intensity cystic component
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o Elevated CA125
PATHOLOGY
General Features Demographics
• Etiology • Age
o Peri- or postmenopausal women
o May arise from endometriosis
o Younger age when associated with endometriosis
• Epidemiology
o Endometrial hyperplasia or carcinoma
o 2nd most common ovarian cancer
▪ In 20-35% of patients
▪ 15-20% of epithelial ovarian cancers
▪ Independent primary tumor rather than metastatic
▪ 20-25% of all ovarian carcinomas
disease o 80% of endometrioid ovarian neoplasms are
▪ Patients with synchronous endometrioid cancers
malignant
tend to be younger, obese, nulliparous, and
▪ 20% borderline
premenopausal, suggesting an underlying o Often present at an earlier stage than other ovarian
hormonal "field effect"
o Lynch syndrome carcinomas
▪ ≥ 50% of patients have stage I or II disease
▪ Lynch syndrome, a.k.a. hereditary nonpolyposis
colorectal cancer (HNPCC) Natural History & Prognosis
▪ Most common histologic subtype of ovarian cancer • Overall better outcome than serous or mucinous
in patients with Lynch syndrome
t
carcinoma, independent of stage
▪ Autosomal dominant genetic condition with
ne
increased risk of colon cancer Treatment
o Endometriosis • Cytoreductive surgery
▪ Up to 42% of cases are associated with pelvic • Neoadjuvant chemotherapy
e.
endometriosis
▪ 1% of patients with endometriosis will develop
yn
malignant transformation (endometrioid
carcinoma, clear cell carcinoma, or both) Consider
– Malignant transformation most commonly • Endometrioid carcinoma in presence of mixed solid
in ovaries, although extragonadal sites can be
bg and cystic ovarian mass in postmenopausal woman
affected with coexisting endometrial neoplasm
Staging, Grading, & Classification Image Interpretation Pearls
• FIGO and TNM staging system for ovarian cancer
ko
• Enhancing mass or soft-tissue mural nodule

within a complex blood-filled adnexal cyst at MR
• Similar to other epithelial lesions imaging should suggest possibility of ovarian cancer
oo
• Mass with variable cystic and solid components

(endometrioid or clear cell) arising in endometrioma
• It should be noted that enhancing nodules can be seen
• Occasionally completely solid in endometrioma in absence of malignancy, due to
o Benign endometriotic tissue
eb
Microscopic Features o Polypoid endometriosis (histologic features

• Tubular glandular pattern embedded in fibrous, simulating an endometrial polyp)
collagenized stroma o Decidualized endometriotic cysts
• Neoplastic cells lack mucin
://
• Mimics endometrial adenocarcinoma with

SELECTED REFERENCES
tp
pseudostratified epithelium as well as metastatic colon

carcinoma 1. Kozawa E et al: Spontaneously ruptured endometrioma
o Ovary and endometrial carcinoma are positive for associated with endometrioid adenocarcinoma: MR
ht
CK7, negative for CK20 immunochemistry (reverse findings. Magn Reson Med Sci. 9(4):233-6, 2010
pattern seen with metastatic colon cancer) 2. Tanaka YO et al: MRI of endometriotic cysts in association
• High incidence of concomitant synchronous with ovarian carcinoma. AJR Am J Roentgenol.
194(2):355-61, 2010
endometrial carcinoma as 2nd primary tumor rather
3. Kitajima K et al: Magnetic resonance imaging findings of
than metastatic disease
o Histologic dissimilarity of tumors endometrioid adenocarcinoma of the ovary. Radiat Med.
25(7):346-54, 2007
o No evidence of spread of endometrial or ovarian
4. Valenzuela P et al: Endometrioid adenocarcinoma of the
cancer ovary and endometriosis. Eur J Obstet Gynecol Reprod Biol.
134(1):83-6, 2007
5. Imaoka I et al: Developing an MR imaging strategy for
CLINICAL ISSUES diagnosis of ovarian masses. Radiographics. 26(5):1431-48,
2006
Presentation
6. Soliman PT et al: Synchronous primary cancers of the
endometrium and ovary: a single institution review of 84
o Increase in abdominal girth cases. Gynecol Oncol. 94(2):456-62, 2004
o Postmenopausal vaginal bleeding
o Hypermenorrhea
5 • Other signs/symptoms
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Ovary
2 left ovarian lesions. The
medial lesion has typical
signal characteristics of an
endometrioma: Intermediate
signal intensity on T2WI (T2
shading). The lateral lesion
shows a mural nodule and is
of high T2 signal intensity (loss
of T2 shading). (Right) Axial
shows high T1 signal intensity
of the medial lesion and
intermediate signal intensity of
the lateral lesion. Note the
mural nodule .
t
ne
e.
yn
same patient shows very high
signal intensity of the medial
bg lesion (endometrioma)
and mild increased signal of
the lateral lesion , which
contains a mural nodule .
ko
The mural nodule is isointense

to pelvic muscles. (Right) Axial
oo
patient shows enhancement

of the mural nodule in
the lateral lesion. Surgery
confirmed 2 endometriomas with
eb
endometrioid carcinoma in the

mural nodule within the lateral
lesion.
://
tp
ht

multilocular pelvic mass with
large, solid, mural components
solid components . A small
amount of pelvic free fluid is
present . The appearance
is nonspecific and cannot
be differentiated from other
malignant ovarian epithelial
neoplasms.
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year-old woman who had a
hysterectomy and bilateral
oophorectomy 10 years earlier
shows a right pelvic mass. The
mass has 2 components: An
anterior component that is
isointense to muscles on T1WI
and a posterior component
that is hyperintense relative to
muscle. (Right) Axial T1WI FS
persistent high signal in the
posterior component of the
lesion , confirming that the
high signal is due to blood
t
products and not fat.
ne
e.
yn
same patient shows that
the anterior component
is slightly hyperintense to
bg
muscle and the posterior
component is of high
signal approaching that of
ko
the surrounding fat. (Right)

same patient shows significant
oo

solid component . Surgery
confirmed endometrioid
carcinoma arising in an
eb
extraovarian endometriotic
cyst.
://
tp
ht

ultrasound shows a
predominantly cystic right
ovarian mass that contains
a solid mural component .
The cystic portion is filled
with homogeneous low-
level echoes, characteristic
of endometrioma. (Right)
Sagittal transvaginal ultrasound
measuring 24 mm.
The fundal portion of the
endometrium shows
relatively lower echogenicity.
Surgery confirmed ovarian
endometrioid and uterine
5 endometrial carcinoma.
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Ovary
a 22-year-old woman shows
a heterogeneous solid left
ovarian mass with areas of
increased vascularity. (Right)
Axial transvaginal color Doppler
shows a right ovarian cystic mass
with homogeneous low-level
echoes and an eccentric mural
vascularized nodule .
t
ne
e.
yn
same patient shows a solid
heterogeneously enhancing left
bg ovarian mass and a fluid
density left ovarian cystic mass
with thin uniform enhancing
wall and no definite mural
ko
nodules. (Right) Axial CECT in

ovarian solid enhancing mass
oo
as well as another anterior

solid pelvic mass , proved
during surgery to be an omental
metastasis.
eb
://
tp
ht
(Left) Coronal CECT in the same

patient shows 3 lesions: The left
ovarian solid mass , a right
ovarian cystic mass , and an
omental mass . (Right) Sagittal
the left ovarian solid mass ,
right ovarian cystic mass ,
and a normal-appearing uterus
. Pathology revealed a left
ovarian endometrioid carcinoma,
a right ovarian borderline
endometrioid carcinoma arising
in an endometrioma, and an
omental metastasis.
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Ovary OVARIAN CLEAR CELL CARCINOMA
Key Facts
• Classified as malignant ovarian epithelial tumor • Endometrioma
Imaging • Benign serous or mucinous cystadenoma of ovary
• When arising de novo • Serous or mucinous adenocarcinoma of ovary
o Indistinguishable from other histologic subtypes of • Ovarian endometrioid carcinoma
OEC Pathology
o Thick-walled, unilocular or multilocular cyst with
peripheral mural soft tissue nodules (often round
• Association with endometriosis (45-49% of cases) is
more common than other types of ovarian cancer (8%)
and few in number) • Increased prevalence of venous thromboembolism
• When arising in endometrioma (Trousseau syndrome)
o Mural nodules with contrast enhancement seem
to be most valuable imaging finding suggestive of Clinical Issues
coexisting carcinoma • Pelvic mass
o T2 shading, characteristic feature of endometrioma, • Pelvic pain
may be lacking in endometriomas developing • Hypercalcemia (most common paraneoplastic
malignant transformation syndrome in ovarian cancer) is more common in clear
t
•
ne
40% of cases are bilateral cell carcinoma (CCC) than in other ovarian cancers
e.
yn
ultrasound shows a
mass containing uniform
bg
low-level echoes, fine
septations , and a large
mural nodule . (Right) Axial
ko
CECT shows a predominantly
cystic mass with solid
enhancing mural components
oo
. There is a small amount of

pelvic ascites .
eb
://
tp
ht

a right ovarian mass .
The mass is composed of
a T1 high signal intensity
component , representing
an endometrioma. Note also a
polypoid solid component ,
isointense to pelvic muscles.
enhancement of the polypoid
solid component . This
is the typical appearance
of malignancy arising in an
endometrioma.
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OVARIAN CLEAR CELL CARCINOMA
Ovary
TERMINOLOGY ▪ Intermediate or high signal nodule in otherwise
intermediate signal mass
Abbreviations ▪ T2 shading, characteristic feature of
• Clear cell carcinoma (CCC) endometriomas, may be lacking in endometrioma
with malignant transformation
Definitions – May be due to dilution of hemorrhagic
• Classified as malignant ovarian epithelial tumor contents by nonhemorrhagic fluid produced by
• First termed mesonephroma to describe ovarian malignant tumor
neoplasm composed of clear and hobnail cells with • T1WI C+
pattern resembling immature glomeruli o Solid components of mass demonstrate marked
enhancement
o Contrast enhancement helps to differentiate blood
IMAGING
clot, which does not enhance, from enhancing solid
General Features projections
o When arising de novo
▪ Indistinguishable from other histologic subtypes of • Grayscale ultrasound
o Cystic adnexal mass containing solid mural
ovarian epithelial carcinoma (OEC)
▪ Thick-walled, unilocular or multilocular cystic components
t
o Cystic component may demonstrate variable
ne
mass with peripheral mural soft-tissue nodules
o May arise within preexisting endometrioma echogenicity due to presence of hemorrhage
▪ Best imaging clues of malignancy in • Color Doppler
o Solid components demonstrate vascularity
endometrioma
e.
– Enhancing mural nodule (most sensitive) Imaging Recommendations
– Loss (absence) of T2 shading in endometriotic
yn
cyst o US, CT, or MR can be used to detect and characterize
– Mural nodule diameter > 3 cm
adnexal mass
– Interval increase in size of cyst ▪ US is most commonly used modality in evaluation
• Location
bg
of adnexal lesion
o 40% bilateral ▪ MR is superior to US and CT in tumor
• Size characterization due to its better soft tissue
o Most often present as large tumors
ko
resolution
• Morphology ▪ CT is most often used in advanced disease to assess
o Usually large cystic mass with 1 or more solid peritoneal carcinomatosis or distant metastases
•
oo
components protruding into cystic portion Protocol advice

o Color Doppler is necessary to assess for blood flow in
CT Findings
• NECT solid-appearing components on US
o Contrast enhancement is essential to demonstrate
eb
o Low-attenuation cystic mass with soft tissue

enhancing solid components on both CT and MR
attenuation solid components
o Cystic component may be of high attenuation due to
://
hemorrhage DIFFERENTIAL DIAGNOSIS

• CECT
Endometrioma
o Large cystic mass with enhancing solid mural
• Endometriomas contain altered blood and may have
tp
components
o Contrast enhancement helps to differentiate thick, irregular walls
• Endometriomas usually do not have enhancing solid
ht
hemorrhage from enhancing solid projections

projections
MR Findings o Enhancing nodules may be seen in an endometrioma
• T1WI in absence of malignancy, due to
o Cystic component may be of varying signal intensity, ▪ Benign endometriotic tissue
from low to very high, depending on hemorrhagic ▪ Polypoid endometriosis (histologic features
content simulating endometrial polyp)
o Solid components have intermediate signal intensity ▪ Decidualized endometriotic cysts
• T1WI FS Benign Serous or Mucinous Cystadenoma of
o Bright signal on T1WI FS within endometriotic cyst
Ovary
• Usually < 4 cm in size
confirms presence of blood products rather than fat
(which would lose signal)
• T2WI • Entirely cystic without solid components
o Arising de novo Serous or Mucinous Adenocarcinoma of Ovary
▪ High signal intensity cystic component
▪ Intermediate to high signal solid components, may
• More complex, usually multiloculated masses
• Tend to present at advanced stages compared to CCC
be heterogeneous
• Tend to occur in older age group
o Arising within endometriotic cyst
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Ovarian Endometrioid Carcinoma • Ethnicity

• May also arise in endometrioma o More common in women of East Asian descent
• Indistinguishable from CCC ▪ 15-25% of all OEC in Japan
▪ 5–13% of all OEC in Western populations

• Although usually presents at early stages, prognosis is
General Features worse when compared stage-by-stage to other types of
• Associated abnormalities OEC
o Association with endometriosis (45-49% of cases) o Due to insensitivity to conventional platinum-based
is more common than with other types of ovarian chemotherapy
cancer (8%) • Recurrence following surgery is common
o Increased prevalence of venous thromboembolism
Treatment
• Cytoreductive (tumor-debulking) surgery
(Trousseau syndrome)
▪ Likely due to secretion of excessive tissue factor
(pro-thrombotic protein) • Chemotherapy: Pre- &/or postoperative surgery
o Poor response to platinum-based chemotherapy
• Staged using FIGO and TNM systems for ovarian cancer DIAGNOSTIC CHECKLIST
t
ne
• Large cystic mass with 1 or more solid nodules Consider
protruding into cyst lumen • CCC in presence of mixed solid and cystic ovarian mass
in postmenopausal woman with
Microscopic Features o Endometriosis
e.
• Clear cell tumors of ovary are almost always malignant o Associated thromboembolic complication
o Benign clear cell tumors are not reported, and o Hypercalcemia
yn
borderline tumors are very rare
• Polyhedral cells containing abundant clear cytoplasm Image Interpretation Pearls
• Enhancing mass or soft tissue mural nodule within
with eccentric nuclei
bg
• Cells grow in aggregates or form tubules complex blood-filled adnexal cyst at MR imaging
• Hobnail cells found in most tumors are characterized
should suggest possibility of ovarian malignancy (CCC
or endometrioid) arising in endometrioma
by prominent bulbous nuclei that protrude beyond
ko
apparent cytoplasmic limits

• At least 2 histogenetic types SELECTED REFERENCES
o Cystic CCC
1. del Carmen MG et al: Clear cell carcinoma of the ovary: a
oo
▪ Frequently associated with endometriosis review of the literature. Gynecol Oncol. 126(3):481-90, 2012
▪ Commonly manifest with stage I disease, with 2. McDermott S et al: MR imaging of malignancies arising
affected patients having a 90% 5-year survival rate in endometriomas and extraovarian endometriosis.
o Adenofibroma-associated CCC
eb
Radiographics. 32(3):845-63, 2012

▪ 5-year survival rate: 50% 3. Siegelman ES et al: MR imaging of endometriosis: ten
imaging pearls. Radiographics. 32(6):1675-91, 2012
://
CLINICAL ISSUES features of ovarian cancers: implications for diagnosis and

Presentation 5. Manabe T et al: Magnetic resonance imaging of endometrial
tp
• Most common signs/symptoms cancer and clear cell cancer. J Comput Assist Tomogr.
o Pelvic mass 31(2):229-35, 2007
ht
o Pelvic pain 6. Sugiyama K et al: Magnetic resonance findings of clear-cell

adenocarcinofibroma of the ovary. Acta Radiol. 48(6):704-6,
o Abdominal swelling due to ovarian enlargement or
2007
ascites 7. Imaoka I et al: Developing an MR imaging strategy for
• Other signs/symptoms diagnosis of ovarian masses. Radiographics. 26(5):1431-48,
o Hypercalcemia (most common paraneoplastic 2006
syndrome in ovarian cancer) is more common in 8. Takano M et al: Clear cell carcinoma of the ovary: a
retrospective multicentre experience of 254 patients with
CCC than in other ovarian cancers
o Thromboembolic complications are common complete surgical staging. Br J Cancer. 2006
•
9. Togashi K. Related Articles et al: Ovarian cancer: the clinical
Clinical profile role of US, CT, and MRI. Eur Radiol. 13 Suppl 4:L87-104,
o Low stage at presentation (stage I/II in 57–81% of 2003
cases) 10. Matsuoka Y et al: MR imaging of clear cell carcinoma of the
▪ Likely due to slow growth of tumor and ovary. Eur Radiol. 11(6):946-51, 2001
presentation of tumors as large pelvic masses
Demographics
• Age
o Occurs most frequently between age 40-70 years
5 ▪ Mean age at presentation is 57 years
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Obgyne Books Full
Ovary
right ovarian mass . The
mass is composed of a T1 high
signal intensity component ,
representing an endometrioma,
and a polypoid solid component
that is isointense to pelvic
muscles. (Right) Coronal T1WI
the right ovarian mass with
a high T1 signal component
and a polypoid component
with T1 signal intensity similar to
muscle.
t
ne
e.
yn
adnexal mass . The high
bg signal intensity component
represents altered blood
in an endometrioma. The
solid component shows
ko
heterogeneous predominantly
high T2 signal intensity. Note
a moderate amount of pelvic
oo
ascites . (Right) Coronal T1WI

shows significant enhancement
of the solid component .
eb
Surgery confirmed clear

cell carcinoma arising in an
endometrioma.
://
tp
ht

predominantly multilocular cystic
mass with septations
and a mural solid enhancing
component . (Right) Coronal
CECT in the same patient again
shows the multilocular cystic
mass with enhancing mural
nodules .
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ultrasound shows a
pelvic mass composed
of a heterogeneous solid
component and a
multilocular cystic component
containing multiple
septa . (Right) Sagittal
transabdominal color and
spectral Doppler ultrasound
increased vascularity of the
solid component of the mass
. Low-resistance flow is seen
on spectral analysis.
t
ne
e.
yn
heterogeneous, hyperintense
solid component and a
bg
containing numerous septa
. A fluid-fluid level is
ko
seen in the dependent portion

of the cystic component.
oo

isointense solid component
and a hypointense cystic
component . The solid
eb
component contains small foci

of high T1 signal intensity
likely due to hemorrhage.
://
tp
ht

heterogeneous, hyperintense
solid components and
a cystic component
containing septa . (Right)
the nonenhancing cystic
component of the tumor
with enhancement of the solid
components .
5
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Ovary
a palpable pelvic mass shows
a left ovarian predominantly
cystic mass with peripheral
enhancing soft tissue nodules
. (Right) Coronal CECT in the
enhancing soft tissue nodules .
t
ne
e.
yn
with a palpable mass shows
bg a left ovarian predominantly
enhancing soft tissue nodules
ko

ovarian cystic mass with
peripheral enhancing soft tissue
oo
nodules .
eb
://
tp
ht

with a palpable mass shows
bilateral ovarian predominantly
cystic masses with peripheral
enhancing soft tissue nodules .
Note also the presence of ascites
and enhancing omental
nodularity due to metastases
ovarian cystic masses with
peripheral-enhancing soft tissue
nodules . Note also the
enlarged metastatic paraaortic
lymph nodes .
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Ovary CARCINOSARCOMA (OVARIAN MIXED MÜLLERIAN TUMOR)
Key Facts
Terminology • Ovarian metastases
• Ovarian carcinosarcoma (OCS) Pathology
o a.k.a.malignant mixed müllerian tumor (MMMT)
• Malignant neoplasms composed of malignant
• Monoclonal tumors, suggesting they are metaplastic
carcinomas
epithelial (carcinoma) and malignant mesenchymal
(sarcoma) elements Clinical Issues
Imaging • Patients tend to be older than women with serous
• Large solid or mixed solid and cystic adnexal mass
ovarian carcinoma
o ~ 60% of patients are 65 and older vs. ~ 45% with
with possible invasion of adjacent organs, ascites, and serous carcinomas
•
peritoneal implants
• Account for 1–4% of malignant ovarian tumors
•
Usually unilateral and large
• Aggressive clinical course and overall poor prognosis
•
Well-capsulated multinodular or multicystic tumors
Avid, homogeneous enhancement of solid
• Treatment for women with advanced stage disease
consists of cytoreductive surgery followed by adjuvant
components chemotherapy
• Other epithelial ovarian malignancies
t
ne
e.
yn
patient shows a predominantly
solid large adnexal mass
bg
with areas of cystic change.
ko
mass with mixed areas of
solid and cystic components.
A small amount of ascitic fluid
is present .
oo
eb
://
tp
ht

a predominantly solid left
ovarian mass with omental
metastases giving the
appearance of omental caking.
MR shows heterogeneous
enhancement of an ovarian
mass . Note an irregular
interface between the posterior
aspect of the mass and the
uterus , suggesting direct
invasion.
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CARCINOSARCOMA (OVARIAN MIXED MÜLLERIAN TUMOR)
Ovary
o Of limited value in detection of small peritoneal
TERMINOLOGY
implants, as normal bowel uptake may obscure small
Abbreviations lesions
• Ovarian carcinosarcoma (OCS) Imaging Recommendations
Synonyms • Best imaging tool
• Malignant mixed müllerian tumor (MMMT) o Contrast-enhanced CT
Definitions
• Protocol advice
o Intravenous contrast medium is mandatory
• Malignant neoplasms composed of malignant o Multiplanar reformatted images are very useful
epithelial (carcinoma) and malignant mesenchymal in evaluation of adjacent organ invasion and
(sarcoma) elements to distinguish liver capsular implants from
intraparenchymal metastases
IMAGING
General Features DIFFERENTIAL DIAGNOSIS
• Best diagnostic clue Other Epithelial Ovarian Malignancies
o Large solid or mixed solid and cystic adnexal mass
with possible invasion of adjacent organs, ascites,
• OCSs are more aggressive and larger than other
epithelial ovarian tumors; however, imaging findings
t
and peritoneal implants are not specific
•
ne
Location
o Usually unilateral Krukenberg Tumor
• Size • Known primary tumor from gastrointestinal tract
• Predominantly solid masses; large amount of ascites is
e.
o Usually very large at presentation (> 10 cm)
• Morphology rare
o Large, well-capsulated multinodular or multicystic
yn
Ovarian Metastases
tumors
o Peritoneal implants ± ascites may be seen
• Most ovarian metastases are predominantly solid
• Clinical presentation often due to primary tumor
bg
CT Findings
• Multinodular or multicystic tumors with avid, PATHOLOGY
homogeneous enhancement of solid components
ko
General Features
MR Findings
• T1WI • Etiology
o Majority of ovarian carcinosarcomas are monoclonal,
o Large adnexal masses of low or intermediate signal
oo
suggesting they are metaplastic carcinomas

intensity
o Areas of intermediate signal intensity represent Staging, Grading, & Classification
proteinaceous fluid within cystic components • Staged as other ovarian carcinomas using FIGO and
eb
o Areas of high signal intensity indicate presence of TNM staging systems

hemorrhage
• T2WI
• Large, well-capsulated multinodular or multicystic
://
o Large, complex adnexal mass of heterogeneous signal

tumors
•
intensity
• Hemorrhage and necrosis are usually present
tp
T1WI C+ FS
o Avid enhancement of solid components, walls, and Microscopic Features
internal septa of cystic lesions • High-grade malignant epithelial (carcinoma) and
ht
Ultrasonographic Findings malignant mesenchymal (sarcoma) elements

• Grayscale ultrasound • Either carcinomatous or sarcomatous component may
predominate
o Large complex cystic and solid or multicystic adnexal
masses
• Epithelial element is most commonly serous carcinoma
o Other subtypes have been reported
o Heterogeneous or hypoechoic solid components
o Bizarre epithelial giant cells are common
• Pulsed Doppler
• Malignant stromal component usually contains
o Low resistance blood flow within solid components
•
hyperchromatic rounded to spindled cells with marked
Color Doppler
nuclear atypia and high mitotic index
o Increased vascularity within solid components and
thick septa
• Homologous OCS contains malignant stromal
elements native to ovary, whereas heterologous OCS
Nuclear Medicine Findings contains sarcomatous tissue not normally found in
• PET/CT ovary, e.g., cartilage, osteoid, and rhabdomyoblasts
o Increased metabolic activity of solid components
o May be useful to evaluate extent of disease, especially
if follow-up surgery is being considered
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Ovary CARCINOSARCOMA (OVARIAN MIXED MÜLLERIAN TUMOR)
predominantly of signet ring cell carcinoma. Arch Gynecol

CLINICAL ISSUES Obstet. 283(6):1403-6, 2011
Presentation 4. Chiu SY et al: Primary malignant mixed müllerian tumor of

the ovary. Taiwan J Obstet Gynecol. 49(1):87-90, 2010
Ling Y et al: [Magnetic resonance imaging of ovarian
o Lower abdominal pain carcinosarcoma: correlation to the clinicopathological
o Abdominal distension findings.] Nan Fang Yi Ke Da Xue Xue Bao. 30(7):1648-50,
• Other signs/symptoms 2010
o Symptoms related to adjacent organ invasion and 6. Su N et al: [Ultrasonographic characteristics of ovarian
metastases carcinosarcoma.] Zhongguo Yi Xue Ke Xue Yuan Xue Bao.
32(1):113-5, 2010
Demographics 7. Yoon JH et al: Magnetic resonance imaging findings in
• Age extrauterine malignant mixed Mullerian tumors: report of
two cases. J Magn Reson Imaging. 32(5):1238-41, 2010
o Patients tend to be older than women with serous
8. Cantrell LA et al: Carcinosarcoma of the ovary a review.
ovarian carcinoma Obstet Gynecol Surv. 64(10):673-80; quiz 697, 2009
o ~ 60% of patients are 65 and older vs. ~ 45% with 9. Hussein MR et al: Primary peritoneal malignant mixed
serous carcinomas mesodermal (Müllerian) tumor. Tumori. 95(4):525-31, 2009
• Epidemiology 10. Navarini R et al: Malignant mixed müllerian tumors of the
o Account for 1–4% of malignant ovarian tumors ovary. Curr Opin Obstet Gynecol. 18(1):20-3, 2006
11. Rutledge TL et al: Carcinosarcoma of the ovary-a case series.
t
Natural History & Prognosis Gynecol Oncol. 100(1):128-32, 2006
• Aggressive clinical course and overall poor prognosis
ne
12. Barnholtz-Sloan JS et al: Survival of women diagnosed
o Stage at diagnosis with malignant, mixed mullerian tumors of the ovary
▪ Stage I tumors: 11.0% (OMMMT). Gynecol Oncol. 93(2):506-12, 2004
13. Brown E et al: Carcinosarcoma of the ovary: 19 years
▪ Stage II tumors: 10.6%
e.
of prospective data from a single center. Cancer.
▪ Stage III tumors: 39.0% 100(10):2148-53, 2004
▪ Stage IV tumors: 22.6%
yn
14. Harris MA et al: Carcinosarcoma of the ovary. Br J Cancer.
▪ Unknown stage: 15.8% 88(5):654-7, 2003
o Survival for both early- and late-stage carcinosarcoma 15. Duska LR et al: Paclitaxel and platinum chemotherapy for
is inferior to serous tumors malignant mixed mullerian tumors of the ovary. Gynecol
bg
▪ 5-year survival rate by stage Oncol. 85(3):459-63, 2002
16. Cho SB et al: Malignant mixed mullerian tumor of the
– Stage I tumors: 65.2%
ovary: imaging findings. Eur Radiol. 11(7):1147-50, 2001
– Stage II tumors: 34.6% 17. Melilli GA et al: Malignant mixed mullerian tumor of the
ko
– Stage III tumors: 18.2% ovary: report of four cases. Eur J Gynaecol Oncol. 22(1):67-9,
– Stage IV tumors: 11.2% 2001
• Older age at presentation and suboptimal debulking are 18. Wei LH et al: Carcinosarcoma of ovary associated with
oo
related to worst prognosis previous radiotherapy. Int J Gynecol Cancer. 11(1):81-4,

2001
Treatment 19. Ariyoshi K et al: Prognostic factors in ovarian
• Management is similar to other ovarian tumors and carcinosarcoma: a clinicopathological and
eb
typically includes cytoreductive surgery followed by immunohistochemical analysis of 23 cases. Histopathology.

adjuvant chemotherapy for women with advanced 37(5):427-36, 2000
20. Sit AS et al: Chemotherapy for malignant mixed Mullerian
stage disease
• tumors of the ovary. Gynecol Oncol. 79(2):196-200, 2000
://
Although platinum and taxane-based chemotherapy

are often used, the ideal chemotherapy regimen for
OCS is not known
tp
o Ifosfamide could be incorporated into treatment of

OCS
ht
▪ Based on its efficacy for uterine carcinosarcoma
• Large, aggressive adnexal lesion with invasion of
adjacent organs, ascites, and peritoneal implants at
time of diagnosis
SELECTED REFERENCES
1. Brustmann H: Ovarian carcinosarcoma associated with
bilateral tubal intraepithelial carcinoma: a case report. Int J
Gynecol Pathol. 32(4):384-9, 2013
2. George EM et al: Carcinosarcoma of the ovary: natural
history, patterns of treatment, and outcome. Gynecol
Oncol. 131(1):42-5, 2013
5 3. Terada T: Ovarian malignant Mullerian mixed tumor

(heterologous) whose epithelial component is composed
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CARCINOSARCOMA (OVARIAN MIXED MÜLLERIAN TUMOR)
Ovary
with a palpable adnexal
mass shows a heterogeneous
multinodular solid mass .
Individual nodules are separated
by hypointense septations
. (Right) Sagittal T2WI MR
heterogeneous multinodular solid
mass with individual nodules
separated by hypointense
septations .
t
ne
e.
yn
ovarian mass of more or
bg less homogeneous intermediate
signal intensity, relative to
that of pelvic skeletal muscle.
ko
in the same patient shows avid

enhancement of the multinodular
right ovarian mass . The
oo
individual nodules are separated

by enhancing septations .
eb
://
tp
ht

a palpable pelvic mass shows
a moderately enhancing left
ovarian mass and a moderate
amount of ascites . (Right)
Sagittal CECT in the same patient
shows the large pelvic mass
displacing the urinary bladder
and uterus anteriorly. The
mass is predominantly solid with
areas of low attenuation, likely
due to necrosis.
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Ovary OVARIAN TRANSITIONAL CELL CARCINOMA
Key Facts
Terminology • Krukenberg tumor
• Ovarian transitional cell tumors are composed of • Subserosal pedunculated leiomyoma
epithelial cells resembling urothelium
Pathology
Imaging • In ~ 30% of cases, there is a 2nd tumor in same ovary
• Usually unilateral • Current WHO classification of ovarian transitional cell
• Brenner cell tumors carcinoma
o Benign Brenner tumors
o Combination of calcifications demonstrated by US
or CT and low signal intensity on T2WI MR o Brenner tumors of borderline malignancy
o Usually small (< 5 cm) o Malignant Brenner tumors
• Transitional cell carcinomas o Transitional cell carcinoma (non-Brenner type)
o Indistinguishable from other malignant epithelial
Clinical Issues
tumors
• Almost all are asymptomatic
Top Differential Diagnoses • Treatment
• Mature teratoma o Benign Brenner tumors are treated with local
• Fibroma/fibrothecoma excision
t
o Malignant tumors are treated like ovarian carcinoma
• Ovarian cancer
ne
e.
yn
relatively homogeneous solid
bg
adnexal mass with minimal
blood flow . (Right) Axial
ko
shows a homogeneous solid
mass anterior to the uterus
. There is small volume
ascites . Pathological
oo
examination revealed a
borderline Brenner cell tumor.
eb
://
tp
ht

adnexal mass composed
of solid component
with minimal blood flow
and a multilocular cystic
component with thick
septa. (Right) Axial CECT
with thick, irregular septa
. Pathological examination
revealed malignant Brenner
cell tumor.
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OVARIAN TRANSITIONAL CELL CARCINOMA
Ovary
TERMINOLOGY ▪ High signal intensity cystic component containing
intermediate to high signal intensity solid
Abbreviations component
• Transitional cell carcinoma (TCC) ▪ Admixture of low and high signal intensity solid
components correlate with transition from benign
Definitions to malignant Brenner histology
• Classified as epithelial ovarian neoplasms • DWI
• Ovarian transitional cell tumors are composed of o Benign Brenner tumor
epithelial cells histologically resembling those of ▪ Low signal intensity and moderate ADC value
urothelium o Borderline and malignant Brenner tumor, TCC
• Brenner tumors comprise the majority of ovarian ▪ High signal intensity and low ADC value
transitional cell tumors • T1WI C+ FS
o Benign Brenner tumor
IMAGING ▪ Avid rapid homogeneous or heterogeneous
enhancement
General Features o Borderline and malignant Brenner tumor, TCC
• Best diagnostic clue ▪ Mild patchy enhancement of solid components
o Benign Brenner tumor and septae with persistent enhancement on
▪ Combination of calcifications demonstrated by US delayed images
t
ne
or CT and low signal intensity on T2WI MR
o Malignant Brenner tumor and TCC Ultrasonographic Findings
▪ Indistinguishable from other malignant epithelial • Grayscale ultrasound
o Benign Brenner tumors
tumors
e.
▪ Most contain solid components
• Location
– Purely hypoechoic solid mass
o Usually unilateral
– Solid mass with multilocular (more common) or
▪ Bilateral lesions in only 5–14% of cases
yn
• Size
unilocular (less common) cystic components
▪ Usually anechoic or low echogenicity of cyst
o Usually small (< 5 cm)
contents
o Borderline and malignant Brenner tumors tend to be
bg
▪ Calcifications are common
larger
– Foci of increased echogenicity ± posterior
CT Findings shadowing
ko
• Benign Brenner tumor ▪ Ascites and fluid in pouch of Douglas are rare
o Borderline and malignant Brenner tumor, TCC
o Solid tumors of low attenuation (lower than that of
muscle) ▪ Hypoechoic complex cystic mass with solid
oo
o May show extensive amorphous calcifications components, irregular cyst walls, or papillary
o Small cysts may be present projections
• Borderline and malignant Brenner tumor, and TCC ▪ Papillary projections and irregular internal walls
eb
o Multilocular cystic mass with solid components are not common

o Solid component may show amorphous ▪ Calcifications are common in malignant Brenner
tumor but not in TCC
•
calcifications
▪ Presence of components devoid of calcifications Color Doppler
://
may suggest transition to malignancy o Benign Brenner tumors

o Nonspecific mild to moderate enhancement of solid ▪ Most show no or minimal flow
tp
components on CECT o Borderline and malignant Brenner tumor, TCC

o TCC lacks amorphous calcifications ▪ Moderate or high flow
ht
MR Findings PET/CT
• T1WI • Minimal FDG uptake may be seen in benign Brenner
o Benign Brenner tumor tumors
▪ Usually entirely solid mass of low signal intensity Imaging Recommendations
▪ Low signal intensity cystic component with
o CECT or MR
homogeneous intermediate signal intensity solid
component
• T2WI DIFFERENTIAL DIAGNOSIS
o Benign Brenner tumor
Mature Teratoma
▪ Usually entirely solid mass of very low signal
intensity • Usually contains fat density, calcifications, &/or teeth
– Due to presence of dense fibrous stroma Fibroma/Fibrothecoma
▪ Heterogeneous solid or multilocular cystic masses
• Can be indistinguishable from a benign Brenner tumor
as both are of very low signal intensity on T2WI;
however, fibromas usually show internal edema and
cystic changes when large
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• Brenner cell tumors usually show moderate o Calcifications can be present in tumor and are
contrast enhancement while fibromas are typically sometimes very extensive
hypovascular •Borderline and malignant transitional tumors
o Typically larger than benign variants
Ovarian Cancer o Almost entirely cystic with solid papillary projections
• Brenner tumors show lower mean signal intensity on o Cysts contain watery or mucoid material
T2WI than other nonfibrous ovarian masses o Malignant tumors are sometimes necrotic and
• Extensive amorphous calcifications are very rare in hemorrhagic
ovarian cancer
• Diffuse peritoneal spreading and ascites is common Microscopic Features
in ovarian carcinoma but it is not a feature of Brenner • Benign Brenner tumors
tumors o Epithelial cell nests growing in a fibrous stroma
• Malignant Brenner tumors and TCC may be o Cells have appearance of urothelial cells with
indistinguishable from malignant epithelial tumors centrally located nuclei that exhibit conspicuous
Krukenberg Tumor grooves ("coffee bean nuclei")
o Clear demarcation between stroma and epithelial
• Usually bilateral with additional finding of primary cells
•
malignancy
Borderline Brenner tumors
Subserosal Pedunculated Leiomyoma o Complex architecture with branching papillae
• Dystrophic-type calcification in leiomyoma usually has
t
covered by urothelial-looking cells
ne
mottled appearance with curvilinear rim o Atypical cell features + mitoses
o Papillae have fibrovascular cores
o No stromal invasion of malignant cells
PATHOLOGY
•
e.
Malignant Brenner tumors
General Features o Invasive epithelial cells in association with benign or
• Etiology
yn
borderline Brenner component
o Recent data suggest tubal origin of Brenner tumors o Cystic structures with occasional papillary structures
through transitional metaplasia and Walthard cell and only small amount of fibrous tissue
o Usually high-grade transitional cell or squamous
nests
bg
• Associated abnormalities carcinomas
o Malignant Brenner tumors likely arise from their
o In ~ 30% of cases, 2nd tumor in same ovary
▪ Most often serous or mucinous cystadenoma benign counterparts
ko
– Cystadenomas may arise from epithelium of •TCC

Brenner tumors o Definite urothelial features are present (similar
▪ Rarely, coexisting tumor is struma ovarii or a to malignant Brenner tumors) but no benign or
oo
teratoma borderline Brenner component identified

o Endometrial hyperplasia in 4-14% o Lacks prominent stromal calcification
o Typically shows undulating, diffuse, insular, and
eb
trabecular growth patterns

• Current WHO classification of ovarian transitional cell o Tumor cell nuclei are oblong or round, often
carcinoma exhibiting nucleoli or longitudinal grooves
o Benign Brenner tumors o Cytoplasm is often pale and granular, rarely clear or
://
o Brenner tumors of borderline malignancy

eosinophilic
o Malignant Brenner tumors
▪ Component of transitional cell carcinoma
tp
intermixed with benign and borderline elements CLINICAL ISSUES

o Transitional cell carcinoma (non-Brenner type)
ht
▪ Only malignant elements

Presentation
▪ May represent morphologic variation of high- • Most common signs/symptoms
o Almost all are asymptomatic and only discovered
grade serous or endometrioid adenocarcinoma
• Malignant tumors are staged according to TNM and incidentally
o Vaginal bleeding
FIGO staging systems
▪ Due to associated endometrial hyperplasia related
Gross Pathologic & Surgical Features to estrogenic activity
• Benign Brenner tumors o Palpable pelvic mass
o Typically small solid tumors o Ascites or Meigs syndrome
▪ Well-circumscribed, unencapsulated, bosselated, o Reports of androgen-secreting tumors causing
firm tumor progressive virilization
▪ Rarely predominantly cystic o Elevated serum CA125 in patients with malignant
– Small cysts are often seen in solid tumors Brenner tumor and TCC
5
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Ovary
▪ Useful as a serum marker of tumor progression and with pathological correlation. J Comput Assist Tomogr.
recurrence 32(4):553-4, 2008
10. Green GE et al: Brenner tumors of the ovary: sonographic
Demographics and computed tomographic imaging features. J Ultrasound
• Age Med. 25(10):1245-51; quiz 1252-4, 2006
o Benign Brenner tumor: 30–70 years 11. Imaoka I et al: Developing an MR imaging strategy for
o Borderline or malignant Brenner tumors: 45–65 years diagnosis of ovarian masses. Radiographics. 26(5):1431-48,
•
2006
Epidemiology 12. Tamai K et al: MR features of physiologic and benign
o Between 1 and 2.5% of all ovarian tumors conditions of the ovary. Eur Radiol. 2006
▪ Vast majority are benign 13. Heye S et al: Left ovarian Brenner tumor. JBR-BTR.
88(5):245-6, 2005
Natural History & Prognosis 14. Takahama J et al: Borderline Brenner tumor of the ovary:
• Benign Brenner tumor MRI findings. Abdom Imaging. 29(4):528-30, 2004
o Benign behavior 15. Silva PD et al: Diagnosis of a small, androgenizing
• Atypical proliferating transitional cell (Brenner) tumor Brenner cell tumor in a postmenopausal woman aided
by laparoscopic salpingo-oophorectomy. A case report. J
o No convincing evidence of malignant behavior
•
Reprod Med. 48(5):381-3, 2003
Malignant Brenner tumor 16. Yoshida S et al: Brenner tumour. Lancet. 362(9387):858,
o Poor prognosis, as 20% present with extraovarian 2003
spread at time of diagnosis 17. Jung SE et al: CT and MR imaging of ovarian tumors
•
t
TCC with emphasis on differential diagnosis. Radiographics.
ne
o Advanced stage ovarian TCC is significantly more 22(6):1305-25, 2002
18. Robboy SJ et al: Pathology of the Female Genital Tract. 1st
chemosensitive than poorly differentiated serous ed. London, UK: Harcourt Health Sciences. 587-92, 2002
carcinoma
o Patients with TCC have better prognoses compared
e.
to patients with all other types of ovarian carcinomas
after standardized chemotherapy
yn
Treatment
• Benign Brenner tumors are treated with local excision
• Malignant Brenner tumors and TCC are treated like
bg
ovarian carcinoma
o Surgical resection followed by cisplatin-based
ko
chemotherapy
oo

• Extensive amorphous calcifications within solid
eb
component is characteristic of Brenner tumors
SELECTED REFERENCES
://
1. Kuhn E et al: Ovarian Brenner tumour: a morphologic and

immunohistochemical analysis suggesting an origin from
tp
fallopian tube epithelium. Eur J Cancer. 49(18):3839-49,

2013
2. Montoriol PF et al: Fibrous tumours of the ovary: aetiologies
ht
and MRI features. Clin Radiol. 68(12):1276-83, 2013

3. Dierickx I et al: Imaging in gynecological disease (7): clinical
and ultrasound features of Brenner tumors of the ovary.
4. Kikukawa K et al: Diffusion-weighted imaging of a
malignant brenner tumor. Magn Reson Med Sci. 11(1):71-4,
2012
5. Toriihara A et al: FDG PET/CT of a benign ovarian Brenner
tumor. Clin Imaging. 36(5):650-3, 2012
6. Tazi EM et al: Transitional cell carcinoma of the ovary: a rare
case and review of literature. World J Surg Oncol. 8:98, 2010
7. Wang XY et al: [CT features of ovarian Brenner tumor
and a report of 9 cases.] Zhonghua Zhong Liu Za Zhi.
32(5):359-62, 2010
8. Oh SN et al: Transitional cell tumor of the ovary: computed
tomographic and magnetic resonance imaging features
with pathological correlation. J Comput Assist Tomogr.
33(1):106-12, 2009
9. Takeuchi M et al: Malignant Brenner tumor with transition
from benign to malignant components: computed
tomographic and magnetic resonance imaging findings 5
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with palpable adnexal mass
shows a right ovarian lesion
with extensive amorphous
calcifications. (Right) Coronal
shows the right ovarian mass
with extensive amorphous
calcifications. Pathological
examination revealed a benign
Brenner cell tumor. The
amorphous calcifications are
characteristic for Brenner cell
tumors.
t
ne
e.
yn
pregnant woman shows an
bg
mass with a more solid
component . (Right) Axial
ko

shows a solid and cystic mass
. The solid component
oo
is heterogeneous with foci

of increased echogenicity
without definite acoustic
shadowing. Pathological
eb
evaluation revealed extensive

stromal calcifications in a
benign Brenner cell tumor.
://
tp
ht

a palpable mass shows a
multilocular cystic adnexal
lesion with a prominent
solid component . (Right)
shows a multilocular cystic
mass with a large solid
component . Pathological
examination revealed ovarian
transitional cell carcinoma.
The appearance of the tumor
is indistinguishable from
other malignant epithelial
neoplasms.
5
112
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Ovary
Doppler ultrasound in a 53-year-
old woman who underwent
hysterectomy and presented
with a palpable pelvic lesion
shows a midline pelvic mass
with small foci of increased
echogenicity without obvious
shadowing. (Right) Sagittal T2WI
a large mass demonstrating
predominantly low signal
intensity with small focal areas of
increased signal intensity .
t
ne
e.
yn
mass demonstrating low
bg signal intensity (relative to pelvic
skeletal muscles) with small focal
areas of increased echogenicity
. (Right) Axial T1WI MR in
ko

pelvic mass demonstrating
homogeneous signal intensity
oo
similar to pelvic skeletal muscles.

eb
://
tp
ht

same patient shows a large pelvic
signal intensity similar to pelvic
skeletal muscles. (Right) Axial
patient shows a large pelvic mass
demonstrating moderate
The MR appearance is similar to
that of ovarian fibroma; however,
the degree of enhancement is
more pronounced than normally
seen with fibromas. Pathological
evaluation revealed benign
Brenner tumor.
5
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Ovary DERMOID (MATURE TERATOMA)
Key Facts
• Classified as benign ovarian germ cell tumor • Endometriomas
Imaging • Bowel
• Usually unilateral • Hemorrhagic cyst
• 3 most common US manifestations • Pedunculated lipoleiomyoma
o Dermoid plug Clinical Issues
o Tip of iceberg • Usually asymptomatic
o Dermoid mesh
• Complications
• Presence of fat on CT or MR is diagnostic o Rupture
• Sebaceous/fat component displays very high signal o Malignant transformation
intensity on T1WI o Torsion
o Suppression of high signal intensity sebum/fat with o Infection
frequency selective fat-saturation is diagnostic •Treatment
• Signal intensity of sebaceous component is variable on o Uncomplicated cases: Excision with conservation of
T2WI ovarian tissue
o Nonsurgical management is advocated if < 6 cm due
t
ne
to slow growth
e.
yn
a diffusely echogenic mass
with no intralesional
bg
blood flow. (Right) Axial
a predominantly anechoic
ko
cyst with highly echogenic
mural nodules (dermoid plugs,
Rokitansky nodules) . The
dermoid plug involving the far
oo
wall shows ill-defined posterior

shadowing caused by the
sebaceous material or hair
eb
contained within the plug.

://
tp
ht
(Left) Axial CECT shows the

characteristic appearance
of dermoid cyst. There is a
predominantly fatty (around
-100 HU) right ovarian mass
containing an eccentric soft
tissue density mural nodule
(dermoid plug) containing
focal calcification or tooth-
like structure . (Right)
Axial T1WI MR (above) and
T1WI +C FS MR (below)
show a right ovarian mass
with a high signal intensity
component which loses
signal on fat-suppressed
sequence, consistent with
macroscopic fat in a dermoid
5 cyst.
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Obgyne Books Full
DERMOID (MATURE TERATOMA)
Ovary
TERMINOLOGY • T1WI C+ FS
o Enhancement of solid component may occur in
Synonyms benign dermoid cyst and does not necessarily
• Dermoid cyst indicate malignancy
• Mature cystic teratoma ▪ Reflects heterogeneity of tissues, which may
contain enhancing elements such as thyroid tissue
Definitions
• Congenital cystic tumor composed of well- Ultrasonographic Findings
differentiated derivations from at least 2 of 3 germ cell • US appearance is dependent on size of dermoid plug,
layers presence and location of calcified elements, and
• Classified as benign ovarian germ cell tumor histologic composition of fatty component
• May be entirely echogenic or mostly cystic
IMAGING
• 3 most common US manifestations
o Cystic lesion with densely echogenic shadowing
General Features nodule projecting into lumen (Rokitansky nodule or
• Best diagnostic clue dermoid plug)
o "Tip of iceberg": Diffusely or partially echogenic mass
o Presence of fat on CT or MR
▪ ~ 6% of mature cystic teratomas do not have fat in usually demonstrating sound attenuation owing to
sebaceous material and hair within cyst cavity
lumen or cyst wall and appear as fluid-containing
t
o "Dermoid mesh": Multiple thin, echogenic lines and
ne
cystic lesions
o Characteristic US appearance is cystic adnexal mass dots caused by hair in cyst cavity
containing echogenic focus with distal acoustic • Other findings
o Shadowing calcified structures such as bone and
shadowing
e.
• Location teeth
o Fluid-fluid level: Sebum layered on serous fluid
o Pure sebum within cyst may be hypoechoic or
yn
o Bilateral in 20% of patients
o May see several within 1 ovary anechoic
o Echogenic focus is often associated with shadowing
• Size
▪ May see progressive fading of sound beyond a
o Vary in size from 0.5 cm to > 40 cm
bg
moderately echogenic mass, which has been
CT Findings shown to contain soft tissue or fat mixed with hair
• Fat attenuation (-90 to -130 HU) within cyst is ▪ May see very bright echogenic focus, which casts a
ko
diagnostic well-demarcated sharp acoustic shadow related to

• Fat has been reported in 93% of cases presence of teeth or bone
• Teeth or calcifications in 56% o Floating nodules, which include fat, hair, and soft
oo
• May see floating mass of hair at fat-fluid interface tissue: Confirm floating elements by changing
• Calcifications may also occur in cyst wall patient position
o Pitfalls in US diagnosis
• May see dermoid plug in wall of cyst ▪ Blood clot within hemorrhagic cysts can appear
eb
• Enhancement of solid component may occur in echogenic

benign dermoid cyst and does not necessarily indicate ▪ Echogenic bowel can frequently be mistaken for
malignancy
://
echogenic portion of teratoma

MR Findings ▪ Perforated appendix with appendicolith has been
• T1WI described as a false-positive finding
tp
o Sebaceous/fat component demonstrates very high Imaging of Complications

signal intensity • Torsion
ht
o Calcification, bone, hair, and fibrous tissue are low o Findings that suggest torsion
signal intensity ▪ Twisted ovarian vascular pedicle is most specific
o Chemical shift (in-phase and opposed-phase)
imaging finding
imaging can help in diagnosis of dermoid cyst in fat- – Whirlpool appearance on imaging
scant lesions ▪ Enlarged ovary with peripheral arrangement of
▪ Loss of signal on opposed-phase compared to in- multiple ovarian follicles
phase T1WI ▪ Uterine deviation toward twisted side
• T1WI FS ▪ Eccentric dermoid cyst wall thickening
o Suppression of high signal intensity sebum/fat is ▪ Mass with high signal intensity rim on T1WI
diagnostic ▪ Absence of ovarian enhancement suggests ovarian
▪ Allows differentiation from blood products in infarction
hemorrhagic cysts, which do not suppress ▪ Midline position of ovary
• T2WI • Rupture
o Signal intensity of sebaceous component is variable o Discontinuity of cyst wall
• DWI o Presence of fat around or away from dermoid cyst
o High signal intensity on DWI and low ADC value of a o Distorted or flattened shape of cyst
o Ascites
mature cystic teratoma is attributable to presence of
keratinoid substance 5
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Obgyne Books Full
o Omental infiltration, and inflammatory masses cystic teratomas, they are typically coarse or tooth-
resembling peritoneal carcinomatosis or tuberculous like, and located in mural nodule or cyst wall
peritonitis o Unlike dermoid cyst, where cysts predominantly
• Malignant transformation contain fatty sebaceous fluid, cysts within IMTs
o Heterogeneously enhancing, irregular solid predominantly exhibit densities and signal
component with transmural extension and invasion intensities similar to simple fluid
of adjacent organs
▪ Mere presence of enhancement of solid
PATHOLOGY
components does not always indicate malignancy
o Presence of obtuse angle between soft tissue and Gross Pathologic & Surgical Features
inner wall of cyst is a common imaging finding of • Cut surface reveals cavity filled with fatty sebaceous
malignant transformation of ovarian teratomas material, which is liquid at body temperature and
• Pseudomyxoma peritonei (PMP) semisolid at room temperature
o Mature cystic teratoma with prominent solid • Surrounding firm capsule of varying thickness
component, large volume of ascites with selective • Usually unilocular (88%) but may be multilocular
sparing of small bowel and its mesentery, and
scalloping of liver surface
• Arising from cyst wall and projecting into lumen is 1
or more Rokitansky nodules, which may contain hair,
• Infection teeth, calcification, and other atypical tissues
o Diffuse pelvic inflammation with stranding of pelvic
•
t
Most of the hair arises from dermoid plug
ne
fat
o Wall thickening and possible cyst rupture Microscopic Features
• Paraneoplastic anti-N-methyl-D-aspartate receptor • Composed of well-differentiated derivatives of 3 germ
encephalitis layers: Ectoderm, mesoderm, and endoderm
e.
o Brain MR may be normal or show mild temporal lobe • Orderly arrangement or tissues in dermoid plug:
signal abnormality on T2WI Cutaneous, bronchial, gastrointestinal tissues, bone,
yn
teeth, etc.
• Squamous epithelium lines wall of cyst
• Compressed ovarian stroma, often hyalinized, covers
Endometriomas
bg external surface
• Transvaginal sonography: Cystic mass with internal • Hair follicles, skin glands, muscle, and other tissues lie
echoes and mural nodules, related to fibrosis or within wall
• Ectodermal tissue is invariably present
ko
desiccated blood and may appear echogenic
• MR: Complex mass or masses • Mesodermal tissue is present in > 90% of cases
o T1WI: High signal intensity that does not suppress • Endodermal tissue is seen in majority of cases
•
oo
with fat saturation Adipose tissue in 67-75% of cases

o T2WI: Shading with varying degrees of intermediate • Teeth in 31% of cases
to low signal intensity (a function of different • Struma ovarii: Accounts for 3% of all cases of ovarian
stages of blood products secondary to repeated
eb
teratomas and is composed predominantly or solely of

hemorrhage) mature thyroid tissue
Bowel
• Intraluminal gas or fecal material can mimic
://
CLINICAL ISSUES
Rokitansky nodule
• Observation of peristalsis helps make diagnosis Presentation
tp
Hemorrhagic Cyst o Usually incidentally found in asymptomatic patient

• Lace-like appearance can mimic dermoid mesh o Symptoms (when present): Abdominal pain,
ht
abdominal mass, swelling, abnormal uterine

Pedunculated Lipoleiomyoma
• Unusual variant of leiomyoma that contains fat bleeding
• Uterine in origin Demographics

Immature Teratoma (IMT) • Age
o Occur most commonly during reproductive years
• Predominantly solid masses that contain fatty ▪ Mean age is 30 years
elements, coarse irregular calcifications, and numerous o Most common benign ovarian tumor in women
cysts of variable sizes younger than 45 years
o Small foci of fat are typically seen interspersed within o Most common ovarian mass in children
solid mass
o Calcifications in IMTs are small, irregularly shaped, • Epidemiology
o 5-25% of all ovarian neoplasms
and scattered throughout tumor, whereas in mature o Most common ovarian neoplasm removed at surgery
5
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Ovary
o Affects a younger age group than epithelial ovarian – Cross-reactivity of tumor and red blood cell
neoplasms (RBC) antigens
o May be encountered throughout lifespan – Production of RBC autoantibodies by tumor
o Rarely seen before puberty – Alteration of RBC molecules by tumor, which
renders them antigenic to host
Natural History & Prognosis o Paraneoplastic anti-N-methyl-D-aspartate-
• Grow slowly, average rate: 1.8 mm per year receptor associated limbic encephalitis
o Growth stops after menopause
• Local recurrence in < 1% after excision
• Reported complications include
o Torsion (16%) Treatment
▪ Most common during pregnancy • Uncomplicated cases: Excision with conservation of
▪ Dermoids involved in torsion are larger than ovarian tissue
average (~ 11 cm on average) • Nonsurgical management is advocated if < 6 cm due to
o Rupture (1–4%) slow growth
▪ Causes leakage of liquefied sebaceous contents
into peritoneum → peritoneal irritation → acute or DIAGNOSTIC CHECKLIST
chronic inflammation
– Acute peritonitis caused by sudden tumor Image Interpretation Pearls
rupture may → shock • Presence of fat is diagnostic
t
– Chronic and recurrent leakage (more common)
ne
→ chronic granulomatous peritonitis (known
as gliomatosis) → dense peritoneal adhesions SELECTED REFERENCES
→ secondary complications (such as bowel 1. Shaaban AM et al: Ovarian malignant germ cell tumors:
e.
obstruction) cellular classification and clinical and imaging features.
▪ May rupture into adjacent viscera Radiographics. 34(3):777-801, 2014
o Malignant transformation (0.17–2%) 2. Chaudhry S et al: Squamous cell carcinoma arising in
yn
▪ Occurs in 6th or 7th decade of life mature cystic teratoma (dermoid cyst)--a rare presentation. J
▪ Any of the constituent tissues of teratoma may
Pak Med Assoc. 63(4):521-3, 2013
3. Momtahen A et al: Mature ovarian cystic teratoma (dermoid
undergo malignant transformation
bg cyst). Ultrasound Q. 28(3):175-7, 2012
– Squamous cell carcinoma is the most commonly 4. Park SB et al: Imaging findings of complications and unusual
associated cancer, representing > 80% of cases manifestations of ovarian teratomas. Radiographics.
– Other malignant tumor types, including 28(4):969-83, 2008
ko
carcinoid, thyroid carcinoma, basal cell 5. Luk J et al: The superinfection of a dermoid cyst. Infect Dis
carcinoma, intestinal adenocarcinoma, Obstet Gynecol. 2007:41473, 2007
melanoma, leiomyosarcoma, angiosarcoma, and 6. Rim SY et al: Malignant transformation of ovarian mature
cystic teratoma. Int J Gynecol Cancer. 16(1):140-4, 2006
oo
chondrosarcoma, may arise

7. Yazici B et al: Floating ball appearance in ovarian cystic
▪ Rokitansky nodule is common site for malignant teratoma. Diagn Interv Radiol. 12(3):136-8, 2006
change 8. Zagame L et al: Growing teratoma syndrome after ovarian
▪ Findings associated with malignant transformation
eb
germ cell tumors. Obstet Gynecol. 108(3 Pt 1):509-14, 2006

include 9. Nakayama T et al: Diffusion-weighted echo-planar MR
– Patient age > 45 years imaging and ADC mapping in the differential diagnosis of
– Tumor diameter > 10 cm ovarian cystic masses: usefulness of detecting keratinoid
://
– Serum squamous carcinoma (SSC) antigen level > substances in mature cystic teratomas. J Magn Reson
Imaging. 22(2):271-8, 2005
2 ng/mL
10. Pereira JM et al: CT and MR imaging of extrahepatic
o Pseudomyxoma peritonei (PMP)
tp
fatty masses of the abdomen and pelvis: techniques,

▪ Clinical syndrome characterized by mucinous diagnosis, differential diagnosis, and pitfalls. Radiographics.
ascites and implants that diffusely involve
ht
25(1):69-85, 2005
peritoneal surfaces 11. Wootton-Gorges SL et al: Giant cystic abdominal masses in
– Source of PMP is almost always appendiceal children. Pediatr Radiol. 35(12):1277-88, 2005
mucinous tumor 12. Kim KA et al: Benign ovarian tumors with solid and cystic
▪ Ovarian PMP due to mucinous tumors, components that mimic malignancy. AJR Am J Roentgenol.
182(5):1259-65, 2004
cystadenomas, low malignant potential tumors,
or invasive carcinomas, arising in appendiceal with emphasis on differential diagnosis. Radiographics.
elements within ovarian mature cystic teratomas 22(6):1305-25, 2002
o Infection (1%) 14. Kim HC et al: Fluid-fluid levels in ovarian teratomas. Abdom
▪ Coliform bacteria are most commonly implicated Imaging. 27(1):100-5, 2002
organisms 15. Outwater EK et al: Ovarian teratomas: tumor types and
o Autoimmune hemolytic anemia (< 1%) imaging characteristics. Radiographics. 21(2):475-90, 2001
▪ Associated with mature cystic teratomas in rare 16. Jeong YY et al: Imaging evaluation of ovarian masses.
Radiographics. 20(5):1445-70, 2000
cases
▪ Removal of tumor results in complete symptom
resolution
▪ Mechanism of hemolysis is not clear, although
several hypotheses have been proposed
5
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shows a diffusely echogenic
ovarian mass with no
internal blood flow. The ovary
contains 2 simple-appearing
follicles . (Right) Axial
ultrasound shows a highly
echogenic mural nodule ,
with ill-defined posterior
shadowing and a "tip of the
iceberg" appearance within
a less echogenic structure
containing uniform low-level
echoes.
t
ne
e.
yn
ultrasound shows another
characteristic appearance
of dermoid cyst. There are
bg
numerous hyperechoic
rounded structures , 1–2
cm in diameter, floating in a
ko
hypoechoic fluid-containing
cystic lesion . (Right)
Axial transvaginal ultrasound
oo
shows the characteristic

dermoid plugs appearing
as echogenic mural nodules
with ill-defined posterior
eb
shadowing. Fine linear

echogenic shadows are
present in the cyst fluid,
representing hair.
://
tp
ht

the characteristic "dermoid
mesh" appearance due to
multiple echogenic lines and
dots caused by hair in the
dermoid cyst. (Right) Sagittal
an ovarian dermoid cyst
with dermoid plug , linear
echogenic lines due to
intracystic hair, and a fat-fluid
level .
5
118
Obgyne Books Full
Ovary
right upper quadrant pain shows
an incidental right ovarian mass
that has the characteristic
features of a dermoid cyst. The
mass is predominantly fatty
(around -100 HU) and contains
an eccentric soft tissue density
mural nodule (dermoid plug) .
Note the acute angle between
the dermoid plug and the cyst
wall . (Right) Coronal CECT
predominantly fatty mass and
the soft tissue density dermoid
t
plug .
ne
e.
yn
year-old woman shows bilateral
ovarian high T2 signal intensity
bg lesions . (Right) Axial T1WI
that the left ovarian lesion
has low T1 signal intensity (due
ko
to simple fluid content) while

the right ovarian structure
has high T1 signal intensity.
oo
High T1 signal intensity in a

nonenhanced study indicates
the presence of fat (as in a
dermoid cyst) or blood products
eb
(as in a hemorrhagic cyst or an

endometrioma).
://
tp
ht

same patient shows suppression
of T1 signal within the right
ovarian lesion , consistent
with intracystic macroscopic fat
and the diagnosis of a dermoid
cyst. (Right) Axial ADC map
homogeneous low ADC value
throughout the right ovarian
lesion . Compare the low
ADC map appearance to that
of the left ovarian simple follicle
. The low ADC value is
due to intratumoral keratinoid
substance.
5
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Obgyne Books Full

predominantly fluid density
right ovarian cystic structure
with a scant amount of fat
density . (Right) Coronal
shows a predominantly fluid
density right ovarian cystic
structure with a scant
amount of fat density . The
amount of fat density within
dermoid cysts varies, and
about 6% of dermoid cysts do
not have fat on imaging and
cannot be differentiated from
t
simple ovarian cysts.
ne
e.
yn
a left ovarian mass
composed of a large high T2
signal intensity component
bg
and a slightly heterogeneous
high signal intensity mural
ko

shows low T1 signal intensity
of the large component
oo
and a high signal intensity

mural portion . The
dominant component has the
same signal intensity as simple
eb
fluid.
://
tp
ht

suppression of the high signal
intensity mural component
, consistent with fat.
enhancement of the left
ovarian tissue stretched
around the periphery of the
lesion, and of the cyst wall,
without enhancing mural
nodules. This lesion was found
on pathological examination
to be predominantly cystic,
containing clear fluid with a
small amount of mural fat,
consistent with a dermoid cyst.
5
120
Obgyne Books Full
Ovary
2 right and 3 left ovarian
complex masses that are
predominantly of high T1 signal
intensity. Bilateral dermoid cysts
can be seen in up to 20% of
patients. (Right) Axial T1WI C
+ FS MR in the same patient
shows loss of signal in bilateral
ovarian masses , consistent
with intralesional macroscopic
fat.
t
ne
e.
yn
right ovarian lobulated mass
of high T2 high signal intensity,
bg containing multiple internal
septa . (Right) Axial T1WI
a right ovarian mass of high T1
ko
signal intensity with internal

hypointense septations.
oo
eb
://
tp
ht

patient shows suppression of the
high signal intensity contents
of the right ovarian mass ,
consistent with intraluminal
fat. (Right) Axial T1WI C+
shows a predominantly fatty
ovarian mass with a small
enhancing mural nodule .
The presence of an enhancing
nodule does not necessarily
indicate malignancy, but is a
reflection of the heterogeneity of
these lesions, which may contain
benign enhancing components,
such as thyroid tissue.
5
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Obgyne Books Full
(Left) Axial NECT in a 25-year-

with acute pelvic pain shows
an enlarged right ovary
with peripheral arrangement
of multiple follicles . (Right)
Axial NECT in the same patient
shows a fat-containing right
ovarian lesion with fat-fluid
level. Right ovarian torsion due
to ovarian dermoid cyst was
confirmed at laparoscopy.
t
ne
e.
yn
with pelvic pain, vaginal
discharge, and fever shows
bg
a fat-containing mass
surrounded by a thick rim of
soft tissue attenuation .
ko
There is dilatation and mucosal

enhancement of the fallopian
tubes and significant
oo
stranding of the pelvic fat

fat-containing left ovarian
eb
mass surrounded by thick

rim of soft tissue density .
Pathology revealed an infected
://
dermoid cyst.
tp
ht

with chronic pelvic pain shows
a right ovarian dermoid ,
containing fat and a dermoid
plug . There is a rim of
fat density surrounding the
dermoid cyst . (Right) Axial
shows a rim of fat density
surrounding the dermoid
cyst . The appearance is
the result of dermoid cyst
rupture with leakage of
its fatty contents. During
surgery, there were extensive
adhesions secondary to
chronic peritoneal irritation.
5
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Obgyne Books Full
Ovary
a predominantly T2 high signal
intensity pelvic mass with a
mural nodule of intermediate
T2 signal intensity. (Right)
patient shows a fluid level
separating 2 components of high
signal intensity. The anterior
component has a higher signal
intensity. There is a T1 low signal
intensity mass that appears to
extend beyond the lesion margin
and has an obtuse angle with
the cyst wall. Notice the floating
hair ball at the fluid interface .
t
ne
e.
yn
same patient shows suppression
of the high signal intensity of
bg the nondependent component
, consistent with intraluminal
fat. The dependent component
does not lose signal and
ko
represents intracystic blood.

(Right) Axial DWI MR (b800)
oo
high signal intensity of the

solid component involving the
posterior wall of the mass .
eb
://
tp
ht

enhancing posterior wall mass
with extension beyond the
margin of the dermoid cyst.
(Right) Sagittal T1WI C+ FS MR
enhancing posterior wall mass
with extension beyond the
wall of the dermoid cyst and
invasion into the uterus . The
presence of an enhancing solid
component with transmural
extension and invasion of
adjacent organs is the best
imaging indication of malignant
degeneration of a dermoid cyst.
5
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Ovary IMMATURE TERATOMA
Key Facts
Terminology • Ovarian cancer
• Classified as ovarian malignant germ cell tumor • Tubo-ovarian abscess
(OMGCT)
Pathology
Imaging • Grading system is based on amount of immature
• Usually unilateral neuroepithelium, which is the most common tissue in
• Predominantly solid masses that contain fatty IMTs
elements, coarse irregular calcifications, and numerous Clinical Issues
•
cysts of variable sizes
• < 1% of all ovarian malignant tumors
• Usually during first 2 decades of life
Unlike mature cystic teratomas where cysts
predominantly contain fatty sebaceous fluid, cysts
within immature teratomas (IMTs) predominantly • Asymptomatic palpable unilateral abdominal mass
exhibit densities similar to simple fluid • Peak incidence between 15 and 19 years of age
• Calcifications in IMTs are small, irregularly shaped, • Responsible for 30% of ovarian cancer deaths in
and scattered throughout tumor women < 20 years of age
Top Differential Diagnoses • Growing teratoma syndrome

o Consists of an enlarging mass that contains mature
• Mature cystic teratoma
t
elements arising during or after chemotherapy
ne
• Mature solid teratomas
e.
yn
shows a heterogeneous
ovarian mass containing
bg
cystic changes and areas
with posterior shadowing
ko
due to tumoral calcifications.
ultrasound shows a
heterogeneous ovarian
oo
mass containing areas

that may be due to fat or
eb
calcifications.
://
tp
ht

mass shows a predominantly
solid, enhancing pelvic mass
containing small foci of
fat density and small fluid-
density cysts . (Right) Axial
shows a predominantly solid
enhancing pelvic mass
containing small foci of fat
density , small fluid-density
cysts , and punctate foci of
calcification .
5
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IMMATURE TERATOMA
Ovary
Abbreviations
• Nonspecific appearance resembling other solid ovarian
neoplasms
• Immature teratoma (IMT) • Heterogeneous solid masses with scattered small,
shadowing calcifications
Definitions
• Malignant form of teratoma containing immature or • Small foci of fat may be difficult to appreciate, whereas
larger fatty components appear as areas of increased
embryonic tissues
• Classified as ovarian malignant germ cell tumor
echogenicity
(OMGCT) Imaging Recommendations
o Both CT and MR perform similarly and demonstrate
IMAGING
characteristic appearance of IMTs
General Features • Protocol advice
• Best diagnostic clue o Fat suppression must be used in MR whenever a high
o Scattered small foci of fat and calcifications within signal intensity ovarian mass is encountered on
predominantly solid heterogeneous mass in a young T1WI
female
• Location
t
ne
▪ Bilateral involvement in < 5% Mature Cystic Teratoma
• Size • IMTs are typically larger than mature teratomas
o Typically large, measuring 14–25 cm • Mature teratomas are predominantly cystic with
e.
• Morphology dense calcifications, whereas immature teratomas are
o Predominantly solid masses that contain fatty predominantly solid with small foci of lipid material
yn
elements, irregular calcifications, and numerous and scattered calcifications
cysts of variable sizes
o IMT without foci of calcifications or fat are Mature Solid Teratomas
• Radiologically indistinguishable from immature
impossible to diagnose preoperatively
bg
teratomas
Radiographic Findings • Mostly solid with no identifiable immature
• Areas of calcifications may be seen on plain radiographs components
• Must be extensively sampled at biopsy to exclude
ko
CT Findings immature teratoma

• Solid component appears as soft tissue density on CT
• Small foci of fat, generally smaller than those seen Ovarian Cancer
oo
in mature cystic teratomas, are typically interspersed • Most common ovarian malignancy that has tendency
within solid mass of early peritoneal spread; majority of patients present
• with peritoneal carcinomatosis (stage III disease)
eb
Unlike mature cystic teratomas, where cysts

predominantly contain fatty sebaceous fluid, cysts • Older patients, with peak incidence in postmenopausal
within IMTs usually exhibit densities similar to simple women
fluid • Frequently bilateral, heterogeneous, mixed cystic
://
o Fatty fluid within cystic compartments may also be and solid irregularly shaped adnexal masses without
seen detectable fat on all imaging modalities
• •
tp
Calcifications in IMTs are small, irregularly shaped, and In general, associated with poor prognosis due to
scattered throughout tumor presentation at advanced stages
o Unlike mature cystic teratomas, where calcifications
ht
are typically coarse or tooth-like and located in mural
• Seen in sexually active young women
nodule or cyst wall
• Patients are usually acutely symptomatic with fever,
MR Findings pelvic/abdominal pain, and vaginal discharge
• Complex solid mass containing cystic areas, enhancing • Unilateral or bilateral inflammatory, thick-walled cystic
soft tissue components, and fat masses associated with infiltrative changes in adjacent
• Solid component exhibits a wide variety of signal pelvic fat and loculated ascites
intensities on T2WI • No detectable fat within lesions
• Fat can be identified, both within cysts and as small foci
within solid mass, due to its high signal intensity on
PATHOLOGY
T1WI and T2WI
o Small foci of fat can be detected on MR using fat- General Features
suppression techniques • Associated abnormalities
• Cysts within IMTs predominantly exhibit signal o Dermoid cyst is grossly identified within immature
intensities similar to simple fluid cystic teratoma in up to 26% of cases or in
• Calcifications may be present but are difficult to contralateral ovary in 10% of cases
identify on MR
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Ovary IMMATURE TERATOMA
Staging, Grading, & Classification o Normalization of previously elevated serum levels of

• Grading system is based on amount of immature AFP and β-hCG
o More common in men after treatment of
neuroepithelium, which is the most common tissue in
IMTs nonseminomatous testicular germ cell tumor
• Staged as ovarian carcinoma using FIGO and TNM o Primary tumor is either a pure immature teratoma
or a mixed germ cell tumor containing immature
staging systems
teratoma elements
Gross Pathologic & Surgical Features o Mechanism of evolution from immature to mature
• Encapsulated masses that are predominantly solid, soft, teratomatous tissue is not fully understood
and fleshy on cut sections ▪ Proposed mechanisms include
• May contain small cysts – Induction of somatic maturation in malignant
o Cystic areas are usually filled with serous fluid, cells by chemotherapy, "chemotherapeutic
mucinous fluid, or fatty sebaceous material retroconversion"
• Cut surface appears nodular and brown to pink or – Selective destruction of immature elements by
gray to white, with frequent areas of necrosis and chemotherapy, leaving behind resistant mature
hemorrhage elements
• Fat, hair, and sebaceous material may be seen
Treatment
Microscopic Features • Stage I, grade 1 tumors (confined to ovary) are treated
• Tissues derived from 3 germ layers are found with
t
with unilateral salpingo-oophorectomy
• Stage I, grades 2 and 3 tumors require a staging
ne
variable admixture of mature and immature elements
o Presence of immature elements is what establishes procedure, adjuvant chemotherapy, and continued
diagnosis follow-up to detect recurrence
e.
CLINICAL ISSUES DIAGNOSTIC CHECKLIST
yn
Presentation Consider
• Most common signs/symptoms • MR for evaluation of primary lesion
o Asymptomatic palpable, unilateral abdominal mass • CT for detection of peritoneal metastases
bg
o Acute abdominal pain in 10% due to hemorrhage,
rupture, or torsion • Usually large unilateral heterogeneous ovarian mass
ko
o Abdominal distention secondary to presence of with solid enhancing components and scattered foci of
calcification and fat
ascites and peritoneal implants
o Vaginal bleeding
oo
o Serum α-fetoprotein (AFP) concentrations are SELECTED REFERENCES

significantly elevated at diagnosis in most ovarian 1. Peterson CM et al: Teratomas: a multimodality review. Curr
IMTs that contain foci of yolk sac tumor (YST); Probl Diagn Radiol. 41(6):210-9, 2012
eb
AFP levels are occasionally mildly elevated in IMTs 2. Chabaud-Williamson M et al: Ovarian-sparing surgery
without a YST component for ovarian teratoma in children. Pediatr Blood Cancer.
57(3):429-34, 2011
Demographics
://
3. Douay-Hauser N et al: Diagnosis and management of an

• Age immature teratoma during ovarian stimulation: a case
o Usually present during first 2 decades of life report. J Med Case Rep. 5:540, 2011
▪ Peak incidence between 15 and 19 years
tp
4. Papadias K et al: Teratomas of the ovary: a clinico-

o Occurrence after menopause is rare pathological evaluation of 87 patients from one institution
• Epidemiology during a 10-year period. Eur J Gynaecol Oncol. 26(4):446-8,
ht
2005
o < 1% of all ovarian malignant tumors 5. Terzic M et al: Immature ovarian teratoma in a young girl:
o 2nd most common OMGCT very short course and lethal outcome. A case report. Int J
▪ 35.6-36.2% of all cases Gynecol Cancer. 15(2):382-4, 2005
o Responsible for 30% of ovarian cancer deaths in 6. Yamaoka T et al: Immature teratoma of the ovary:
women < 20 years of age correlation of MR imaging and pathologic findings. Eur
Radiol. 13(2):313-9, 2003
Natural History & Prognosis 7. Jung SE et al: CT and MR imaging of ovarian tumors
• Prognosis depends on stage and grade of tumor at with emphasis on differential diagnosis. Radiographics.
22(6):1305-25, 2002
presentation
• 10-year survival rates 8. Outwater EK et al: Ovarian teratomas: tumor types and
imaging characteristics. Radiographics. 21(2):475-90, 2001
o Grade 1: 82%
9. O'Connor DM et al: The influence of grade on the outcome
o Grade 2: 62% of stage I ovarian immature (malignant) teratomas and
o Grade 3: 30% the reproducibility of grading. Int J Gynecol Pathol.
• Growing teratoma syndrome 13(4):283-9, 1994
o Consists of an enlarging mass that contains mature
elements arising during or after chemotherapy
▪ Masses can be located in the peritoneum,
5 retroperitoneum, liver, lungs
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IMMATURE TERATOMA
Ovary
(Left) Anteroposterior radiograph
of the abdomen in a 5-month-
old girl shows scattered areas of
irregular calcification . (Right)
pelvic mass containing sheets
of calcifications and cystic
changes .
t
ne
e.
yn
old girl who presented with a
palpable abdominal mass shows
bg a heterogeneously enhancing
pelvic mass . (Right) Coronal
the heterogeneously enhancing
ko
pelvic mass . In the absence

of fat or calcifications, the
imaging appearance of this
oo
mass is nonspecific. Pathology

revealed high-grade immature
teratoma.
eb
://
tp
ht

woman obtained 8 months after
resection and chemotherapy for
an ovarian immature teratoma
shows a highly echogenic right
hepatic lobe mass . (Right)
shows a fat-density liver mass
, which was not present
on her initial CT scan. Her α-
fetoprotein (AFP) and β-hCG
were negative (she initially
had ↑ AFP). Biopsy of the liver
lesion showed only mature
teratomatous elements. This is
an example of growing teratoma
syndrome.
5
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Obgyne Books Full
Ovary DYSGERMINOMA
Key Facts
Terminology • US
• Malignant germ cell tumor of ovary o Solid mass divided into component lobules with
heterogeneous echogenicity, smooth lobulated
Imaging contours, and well-defined borders
• With few exceptions, dysgerminomas are o Prominent flow in septa on Doppler US
characteristically purely solid
• Usually unilateral Pathology
• Microscopic appearance identical to testicular
• Typically present as large masses
• CECT
seminomas
o Multilobulated solid mass with relatively Clinical Issues
o Speckled calcifications may be present
• 5-year survival rates: 95% for early stage and 65% for
advanced stage
• MR • Treatment for stage IA
o T1WI: Predominantly solid mass hypointense to o Standard of care is fertility-sparing unilateral
muscle salpingo-oophorectomy followed by surveillance
o T1WI C+: Soft tissue components demonstrate • Treatment for stages II and III
o Hysterectomy and bilateral salpingo-oophorectomy
t
relatively homogeneous enhancement
o T2WI: Isointense or slightly hyperintense to muscle
ne
followed by platinum-based chemotherapy
e.
yn
solid ovarian mass with
slightly increased vascularity.
bg
shows an ovarian mass
ko
with increased vascularity in
a radial distribution within
fibrovascular septa separating
individual tumor lobules.
oo
eb
://
tp
ht

a solid slightly enhancing
multilobulated ovarian mass
with enhancing septa
separating the mass
into individual lobules.
(Right) Coronal T2WI MR
shows a predominantly
solid multilobulated mass
of high signal intensity
relative to skeletal muscles.
The tumor is separated into
lobules by low signal intensity
fibrovascular septa . There
is an associated dermoid cyst
in the same ovary.
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DYSGERMINOMA
Ovary
o US, CT, or MR can be used to detect and characterize
TERMINOLOGY
an adnexal mass
Definitions o MR is superior to US and CT in tumor
• Malignant ovarian tumor classified as germ cell tumor characterization due to its better soft tissue
resolution
IMAGING
• Protocol advice
o Contrast-enhanced CT and MR imaging, or color
General Features or power Doppler US, is necessary to demonstrate
• Best diagnostic clue fibrovascular septae within a dysgerminoma
o Characteristically purely solid, multilobulated tumor
divided by fibrovascular septa DIFFERENTIAL DIAGNOSIS
▪ Cases of multilocular cystic masses with papillary
projections and irregular septations that mimic Epithelial (Serous and Mucinous) Tumors of
epithelial ovarian neoplasms have also been Ovary
described • More complex, usually multiloculated cystic masses
• Location • Mainly cystic tumors containing solid components
▪ May be bilateral in 6.5-10% of cases Teratoma
• • Complex mass with cystic and solid components
t
Size
• Contains fat and calcifications
ne
o Usually presents as large mass
▪ Mean diameter: 15 cm
Sex Cord-Stromal Tumors of Ovary
• Morphology
• Typically solid ovarian masses
o Large, lobulated soft tissue mass
e.
• Often manifest with tumor-mediated hormonal effects
CT Findings
• Multilobulated solid mass with relatively homogeneous Ovarian Metastasis
yn
enhancement • Most are solid or mixture of solid and cystic tumors
• Enhancing fibrovascular septae can be seen • Clinical presentation often related to primary disease
• Areas of cystic change may represent hemorrhage or
bg
necrosis PATHOLOGY
• Calcifications may be present, usually in a speckled General Features
ko
pattern
MR Findings • Associated abnormalities
o Increased incidence of dysgerminomas in dysgenetic
• T1WI
oo
gonads of 46,XY patients with pure (or complete)

o Predominantly solid mass, hypointense relative to
gonadal dysgenesis
pelvic skeletal muscles
o Septa are difficult to appreciate on T1WI • Dysgerminoma is ovarian counterpart to testicular
seminoma
eb
o Hemorrhage in mass is seen as high signal intensity

components
• Pure dysgerminomas do not secrete hormones
o 5% of tumors contain syncytiotrophoblasts, which
• T2WI
produce β-hCG
o Isointense or slightly hyperintense to skeletal
://
o Pure dysgerminoma does not produce α-fetoprotein

muscles (AFP)
o Septa are usually hypointense or isointense to muscle
•
tp
Serum LDH and alkaline phosphatase are often

▪ May be hyperintense when edematous nonspecifically elevated
o Necrotic areas demonstrate high signal intensity
•
ht
T1WI C+ Staging, Grading, & Classification

o Soft tissue components demonstrate relatively • Staged as ovarian carcinoma using FIGO and TNM
homogeneous enhancement staging systems
o Fibrovascular septae between lobules demonstrate
marked enhancement
• Characteristically solid and well encapsulated
Ultrasonographic Findings • Large, with mean diameter of 15 cm
• Grayscale ultrasound • In section, it is lobulated, soft, and fleshy
o Solid mass divided into component lobules of • Areas of coagulative necrosis and hemorrhage that are
heterogeneous echogenicity, smooth lobulated typically associated with cystic change may be seen
contours, and well-defined borders
o Necrotic/cystic portions are seen as anechoic areas Microscopic Features
• Color Doppler • Characteristic microscopic appearance identical to that
o May demonstrate prominent flow in fibrovascular of testicular seminomas
o Composed of uniform population of rounded cells
septae
that resemble primordial germ cells in well-defined
Imaging Recommendations nests, separated by fibrous strands and infiltrated by
• Best imaging tool T lymphocytes
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Ovary DYSGERMINOMA
• Cells have clear to eosinophilic cytoplasm and central, DIAGNOSTIC CHECKLIST

large, rounded or flattened nucleus that contains 1 or
several prominent nucleoli Consider
o Mitoses are often numerous • Dysgerminoma should be considered in differential
diagnosis of young patient with pelvic mass, ascites,
and pleural effusion
CLINICAL ISSUES
• In cases of dysgerminomas, nodal metastases are more
Presentation likely than peritoneal metastases (which are more
• Most common signs/symptoms commonly seen in epithelial ovarian cancers)
o Abdominal/pelvic pain Image Interpretation Pearls
o Abdominal/pelvic mass
o Marked abdominal distension due to large size of • Imaging findings of large solid ovarian mass with
intervening fibrovascular septae in young patient
mass &/or ascites should raise possibility of dysgerminoma
o Constipation
o Nausea and vomiting SELECTED REFERENCES
o Urinary symptoms 1. Ajao M et al: Ovarian dysgerminoma: a case report and
• Clinical profile literature review. Mil Med. 178(8):e954-5, 2013
o Most commonly present with abdominal pain &/or 2. Guerriero S et al: Imaging of gynecological disease
t
ne
(6): clinical and ultrasound characteristics of ovarian
palpable abdominal mass
o 15-20% are diagnosed during pregnancy or in dysgerminoma. Ultrasound Obstet Gynecol. 37(5):596-602,
2011
postpartum period 3. Shanbhogue AK et al: Clinical syndromes associated with
e.
Demographics ovarian neoplasms: a comprehensive review. Radiographics.
• Age 4.
30(4):903-19, 2010
Aldhafery BF: Ovarian dysgerminoma in two sisters. J Family
o Most (75% of cases) occur in adolescence and early
yn
Community Med. 15(3):127-31, 2008
adulthood 5. De Backer A et al: Ovarian germ cell tumors in children:
▪ May occur at any age, with reported cases ranging a clinical study of 66 patients. Pediatr Blood Cancer.
between ages of 7 months and 70 years
bg 46(4):459-64, 2006
▪ 10% occur in prepubertal girls 6. Imaoka I et al: Developing an MR imaging strategy for
• Epidemiology
diagnosis of ovarian masses. Radiographics. 26(5):1431-48,
2006
o Age-adjusted incidence rate per 100,000 women-
ko
7. Boran N et al: Pregnancy outcomes and menstrual
years is 0.109 function after fertility sparing surgery for pure ovarian
o Most common ovarian malignant germ cell tumor dysgerminomas. Arch Gynecol Obstet. 271(2):104-8, 2005
(OMGCT) 8. Gucer F et al: Ovarian dysgerminoma associated with
oo
▪ 32.8-37.5% of all OMGCTs Pseudo-Meigs' syndrome and functioning ovarian stroma: a

▪ 1-2% of primary ovarian neoplasms case report. Gynecol Oncol. 97(2):681-4, 2005
9. Lu KH et al: Update on the management of ovarian germ cell
eb
Natural History & Prognosis tumors. J Reprod Med. 50(6):417-25, 2005

• 5-year survival rates: 95% for early stage and 65% for 10. Guven S et al: Management of ovarian dysgerminoma
during a pregnancy complicated by preeclampsia; a case
advanced stage
://
Treatment 11. Ueno T et al: Spectrum of germ cell tumors: from head to
• Stage IA
12.
toe. Radiographics. 24(2):387-404, 2004
Togashi K. Related Articles et al: Ovarian cancer: the clinical
o Fertility-sparing unilateral salpingo-oophorectomy,
tp
role of US, CT, and MRI. Eur Radiol. 13 Suppl 4:L87-104,

followed by surveillance, is standard of care 2003
o 15-25% recurrence rate, but almost all are salvaged 13. Jung SE et al: CT and MR imaging of ovarian tumors
ht
with chemotherapy with emphasis on differential diagnosis. Radiographics.

• Stages II and III 22(6):1305-25, 2002
o Surgical resection followed by platinum-based 14. Akyuz C et al: Malignant ovarian tumors in children: 22
years of experience at a single institution. J Pediatr Hematol
chemotherapy
Oncol. 22(5):422-7, 2000
▪ Hysterectomy and bilateral salpingo-
15. Ayhan A et al: Pure dysgerminoma of the ovary: a review of
oophorectomy are recommended 45 well staged cases. Eur J Gynaecol Oncol. 21(1):98-101,
▪ Cytoreduction is achieved by resecting as much 2000
peritoneal disease and adenopathy as can be safely 16. Tanaka YO et al: Ovarian dysgerminoma: MR and CT
accomplished appearance. J Comput Assist Tomogr. 18(3):443-8, 1994
– Urinary tract resection and extensive bowel
resection are not recommended, considering
highly chemosensitive nature of this tumor
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DYSGERMINOMA
Ovary
(Left) Coronal T1WI MR in a 17-
year-old girl shows a lobulated
left ovarian mass . The mass
is isointense to muscle on T1WI.
the same patient shows a left
ovarian mass . The mass
is predominantly solid and
shows slightly higher signal
intensity compared with skeletal
muscle. Small areas of high signal
intensity are present due to
necrosis.
t
ne
e.
yn
same patient shows that the left
ovarian mass displays slightly
bg higher signal intensity compared
with skeletal muscle. Small
areas of high signal intensity
are present due to necrosis.
ko

lobulated left ovarian mass
oo
with homogeneous enhancement

following administration of
gadolinium contrast.
eb
://
tp
ht

year-old woman shows a solid
homogeneously enhancing left
ovarian mass . (Right) Axial
an enlarged left paraaortic lymph
node . Malignant ovarian
germ cell tumors are staged
similar to epithelial tumors. The
presence of regional adenopathy
makes this a stage IIIC disease.
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Ovary OVARIAN YOLK SAC TUMOR
Key Facts
Terminology o Embryonal carcinoma
• Ovarian malignant germ cell tumor (OMGCT) • Mature cystic teratoma
• Ovarian malignant epithelial neoplasms
Imaging
• Strongly enhancing solid mass with a varying amount Pathology
of cystic portions and hemorrhage • Contralateral ovary contains a dermoid cyst in ~ 10%
• Usually unilateral of cases
• Mean diameter of 15 cm • Schiller-Duval bodies are pathognomonic features
• Predominantly solid mass containing irregular cystic, Clinical Issues
hemorrhagic, or necrotic areas
• Bright dot sign = small enhancing foci in mass wall or • Short duration of symptoms (1-4 weeks) as these
tumors grow rapidly
solid components
• Capsular tears = defects within wall of mass • Most commonly occur in women in 2nd and 3rd
decades of life
Top Differential Diagnoses • Highly malignant tumors with poor prognosis
• Other malignant germ cell tumors • Combination of cytoreductive surgery and
o Dysgerminoma chemotherapy
• Elevated serum α-fetoprotein in majority of patients
t
o Choriocarcinoma
ne
e.
yn
power Doppler ultrasound
bg
anechoic areas of cystic
changes . The mass shows
heterogeneous increased
ko
echogenicity. (Right) Axial
solid ovarian mass with
oo
anechoic area of cystic change

. The solid component
shows heterogeneous
eb
echogenicity with tiny cystic

spaces.
://
tp
ht

a strongly enhancing,
predominantly solid pelvic
mass containing necrotic
areas. Note the presence
of ascites and central
intratumoral vessels .
(Right) Gross pathologic image
an 8 cm solid mass. Note the
presence of capsular rupture
. Pathologic evaluation
revealed malignant yolk sac
tumor of the right ovary.
5
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OVARIAN YOLK SAC TUMOR
Ovary
TERMINOLOGY • Cystic areas are anechoic or hypoechoic
• Multiple vessels may be seen within solid mass
Abbreviations
• Yolk sac tumor (YST) DIFFERENTIAL DIAGNOSIS
Synonyms
• Endodermal sinus tumor Other Malignant Germ Cell Tumors
• Dysgerminoma
Definitions o Usually a very large lobulated solid mass containing
• Classified as ovarian malignant germ cell tumor multiple fibrovascular septa
(OMGCT) o Calcifications may be present
o Normal α-fetoprotein levels
IMAGING • Choriocarcinoma
o History of recent intra-/extrauterine pregnancy in
General Features the case of gestational type
• Best diagnostic clue o Presence of intra-/extrauterine trophoblastic disease,
o Strongly enhancing solid mass with varying amount ovarian theca luteum cyst, or corpus luteum cyst in
of cystic components and hemorrhage gestational choriocarcinoma
• Location o Normal α-fetoprotein levels
o Markedly elevated β-hCG levels
t
•
ne
▪ Bilateral in < 5% of patients Embryonal carcinoma
• Size o Usually very large mass at presentation
o Serum β-hCG levels are usually elevated
o Mean diameter: 15 cm
• •
e.
Morphology Dysgerminoma, nongestational choriocarcinoma, and
o Predominantly solid mass containing irregular cystic, embryonal carcinoma may coexist with yolk sac tumor
and can be very difficult to distinguish on imaging
yn
hemorrhagic, or necrotic areas
o Outer contour is usually smooth alone
o Bright dot sign Mature Cystic Teratoma
▪ Common finding described as enhancing foci • Fat-containing mass with peripheral blood flow and
bg
within wall or solid components seen on contrast- avascular central solid portion (floating Rokitansky
enhanced CT and MR nodule on fat-fluid interface)
▪ Attributed to dilated vessels, considering highly
ko
vascular nature of these tumors Ovarian Malignant Epithelial Neoplasms

▪ Although common, this sign is not • Usually bilateral rather than unilateral
pathognomonic • Older age group
oo
o Capsular tears • Normal α-fetoprotein levels and elevated CA125 levels

▪ Correspond to tears/defects in wall of mass seen on
pathological examination
PATHOLOGY
eb
CT Findings
• Enhancing solid mass with areas of low attenuation General Features
representing necrosis &/or hemorrhage • Associated abnormalities
://
• Bright dot sign o Contralateral ovary contains a dermoid cyst in ~ 10%

• Capsular tears of cases
tp
MR Findings Staging, Grading, & Classification

• T1WI • Staged as ovarian carcinoma using FIGO and TNM
ht
o Mainly solid mass of low signal intensity staging systems

o Portions of high signal intensity may be present due Gross Pathologic & Surgical Features
to hemorrhage • Large encapsulated masses with smooth external
• T2WI surface
o Heterogeneous, high signal intensity, predominantly • On cross section, YSTs characteristically show mixed
solid mass solid and cystic components
o Areas of very high signal intensity represent • Solid components are soft gray to yellow, with
hemorrhage extensive areas of hemorrhage and necrosis
o Multiple signal voids can be seen related to • Cysts (varying from a few mm to 2 cm in diameter) are
hypervascularity of tumor scattered diffusely throughout tissue, giving neoplasm
• T1WI C+ a soft, wet, honeycombed appearance
o Strong peripheral enhancement due to tumor • Capsular tears are seen in 27% of cases
hypervascularity and irregular central necrosis
o Bright dot sign
• YSTs can grow very rapidly
o Can reach enormous sizes in just a few months
• Predominantly solid mass with heterogeneous
echogenicity and cystic spaces divided by septa 5
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Ovary OVARIAN YOLK SAC TUMOR
Microscopic Features DIAGNOSTIC CHECKLIST

• YSTs are germ cell tumors displaying cellular structures Consider
that resemble those of primitive yolk sac (vitelline
elements) • Diagnosis of YST should be considered in girl or young
• Varied microscopic patterns may be present that differ woman presenting with large complex pelvic mass and
considerably from each other but frequently observed elevated serum α-fetoprotein
in same tumor Image Interpretation Pearls
o Reticular pattern is most common pattern, forming
a honeycomb network of variably sized cystic spaces • Prominent intratumoral signal voids and peripheral
strong enhancement on MR
lined by cells with clear cytoplasm and prominent
nucleoli
• Schiller-Duval bodies SELECTED REFERENCES
o Pathognomonic feature of YSTs 1. Alotaibi MO et al: Imaging of ovarian teratomas in children:
o Composed of isolated papillary projections with a 9-year review. Can Assoc Radiol J. 61(1):23-8, 2010
a central blood vessel and peripheral sleeve of 2. Lal A et al: Endodermal sinus tumor: a rare cause of calcified
embryonic epithelial cells peritoneal implants. Cancer Imaging. 9:29-31, 2009
o Their absence does not preclude diagnosis of YST if 3. Choi HJ et al: Yolk sac tumor of the ovary: CT findings.
Abdom Imaging. 33(6):736-9, 2008
appearance of tumor is otherwise typical
o Present in 20% of tumors 4. De Backer A et al: Ovarian germ cell tumors in children:
t
a clinical study of 66 patients. Pediatr Blood Cancer.
ne
46(4):459-64, 2006
CLINICAL ISSUES 5. Aoki Y et al: Yolk sac tumor of the ovary during pregnancy: a
case report. Gynecol Oncol. 99(2):497-9, 2005
Presentation 6. Ayhan A et al: Endodermal sinus tumor of the ovary: the
e.
• Most common signs/symptoms Hacettepe University experience. Eur J Obstet Gynecol
Reprod Biol. 123(2):230-4, 2005
o Abdominal pain and palpable abdominal and pelvic
yn
7. Ulbright TM: Germ cell tumors of the gonads: a selective
mass review emphasizing problems in differential diagnosis,
o Short duration of symptoms (1-4 weeks) as these newly appreciated, and controversial issues. Mod Pathol. 18
tumors grow rapidly Suppl 2:S61-79, 2005
•
bg
8. Young RH: Sex cord-stromal tumors of the ovary and testis:
o Increasing abdominal girth, abdominal distension, their similarities and differences with consideration of
selected problems. Mod Pathol. 18 Suppl 2:S81-98, 2005
weight loss 9. Lopez JM et al: Ovarian yolk sac tumor associated with
ko
o Acute abdominal pain in cases of tumor torsion or
endometrioid carcinoma and mucinous cystadenoma of the
rupture (very rare) ovary. Ann Diagn Pathol. 7(5):300-5, 2003
o Elevated serum α-fetoprotein in majority of patients 10. Nawa A et al: Prognostic factors of patients with yolk sac
oo
tumors of the ovary. Am J Obstet Gynecol. 184(6):1182-8,

Demographics 2001
• Age 11. Oh C et al: Ovarian endodermal sinus tumor in a
o Most commonly occur in women in 2nd and 3rd postmenopausal woman. Gynecol Oncol. 82(2):392-4, 2001
eb
decades of life 12. Yamaoka T et al: Yolk sac tumor of the ovary: radiologic-
o Rare in women > 40 years of age pathologic correlation in four cases. J Comput Assist
• Epidemiology
Tomogr. 24(4):605-9, 2000
://
o ~ 1% of all malignant ovarian tumors

o 3rd most common ovarian malignant germ cell
tp
tumor (OMGCT)
▪ 14.5-16.4% of all OMGCTs
o 9-16% of pediatric ovarian tumors
ht

• Highly malignant tumors with poor prognosis
o Worst prognosis among OMGCTs
• 5-year survival rate varies according to stage at
diagnosis
o Stage I: 95%
o Stage II: 75%
o Stage III: 30%
o Stage IV: 25%
• Worse prognosis is associated with residual tumor size
of > 2 cm and presence of > 100 mL of ascites
Treatment
• Combination of cytoreductive surgery and
chemotherapy
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OVARIAN YOLK SAC TUMOR
Ovary
(Left) Axial CECT in an 18-year-
with abdominal mass shows
a predominantly solid ovarian
mass with focal areas of
necrosis . There is subcapsular
fluid collection and capsular
tear with peritumoral fluid
predominantly solid mass
with areas of necrosis and cystic
change.
t
ne
e.
yn
an abdominal mass shows a
bg predominantly solid ovarian
tumor with focal areas of
necrosis . There is a large
ko

patient shows a solid ovarian
mass with areas of necrosis
oo
and cystic changes. There is a

capsular tear with tumor
protruding through the capsular
defect.
eb
://
tp
ht

old girl shows a predominantly
solid left ovarian mass with
areas of tumor necrosis. There
is moderate ascites and
enhancing peritoneal masses
due to peritoneal metastases.
patient shows a large peritoneal
metastatic mass filling the
posterior cul-de-sac.
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Ovary OVARIAN CHORIOCARCINOMA
Key Facts
Terminology • Tubo-ovarian abscess
• Malignant tumor of ovary with trophoblastic • Massive ovarian edema
differentiation
Pathology
• 2 forms • Ovarian cases should be distinguished from metastatic
o Nongestational choriocarcinoma
o Gestational choriocarcinoma gestational choriocarcinoma
o Concomitant or proximate gestation almost always
Imaging indicates the latter
• Typically unilateral, hypervascular adnexal solid mass o Presence of other germ cell components indicate
primary ovarian tumor
with central hemorrhage and necrosis
• Avid contrast enhancement is seen in peripheral solid Clinical Issues
component of mass
• Elevated serum β-hCG
Top Differential Diagnoses • 2.1-3.4% of all OMGCTs
• Ectopic pregnancy • Highly malignant neoplasm showing invasion of
• Gestational ovarian choriocarcinoma pelvic structures and spread into peritoneal cavity
• Other malignant germ cell tumors • Treatment
t
• Sclerosing stromal tumor o Hysterectomy and bilateral oophorectomy
ne
o Adjuvant chemotherapy
e.
yn
ultrasound in a young
woman with elevated β-
hCG shows a heterogeneous
bg
solid adnexal lesion
situated anterosuperior to
the uterus . (Right) Axial
ko
shows a solid left adnexal
mass with avid peripheral
oo
The diagnosis of primary

ovarian choriocarcinoma
should be considered in a
young woman with elevated β-
eb
hCG and solid ovarian mass.

://
tp
ht

large pelvic mass of mixed
attenuation with large cystic
spaces. Note the presence of
a large low-attenuation area
indicative of necrosis/
hemorrhage. (Right) Gross
pathology in the same patient
shows a solid mass with a
large area of necrosis and
hemorrhage . Pathology
showed pure nongestational
ovarian choriocarcinoma.
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Ovary
o Peritoneal thickening &/or peritoneal implants,
TERMINOLOGY
if present, are best appreciated on delayed (5-10
Definitions minute) images
• Malignant tumor of ovary with trophoblastic Ultrasonographic Findings
differentiation
• 2 forms of ovarian choriocarcinoma exist • Grayscale ultrasound
o Predominantly solid adnexal mass
o Nongestational choriocarcinoma
o Anechoic cystic areas represent necrosis and
▪ Classified as ovarian germ cell tumor
hemorrhage
▪ Tumor may be admixed with other malignant germ o Intrauterine and ectopic pregnancy should be
cell components
o Gestational choriocarcinoma ruled out in cases of nongestational ovarian
choriocarcinoma
▪ Represent metastasis from primary gestational
choriocarcinoma in uterus • Color Doppler
o Marked blood flow within solid components
▪ Rarely, may arise from ovarian ectopic pregnancy
• Power Doppler
o Solid components demonstrate marked blood flow
IMAGING with low resistance
t
o Typically unilateral, hypervascular adnexal mass
ne
o US for initial diagnosis and to rule out intra-/
with central hemorrhage and necrosis extrauterine pregnancy
• Location o CECT/MR for lesion characterization and evaluation
o Unilateral
e.
of local extent of tumor
• Size o CT for evaluation of distant metastases (lung, liver,
o Usually large mass brain)
yn
• Morphology
o Solid mass with areas of necrosis and hemorrhage
CT Findings
bg
Gestational Ovarian Choriocarcinoma
• NECT • Evidence of intra-/extrauterine trophoblastic disease,
o Large complex pelvic mass
ovarian theca luteum cyst, or corpus luteum cyst
o Central low-attenuation areas represent necrosis
• Recent intra-/extrauterine pregnancy
ko
o Hemorrhage can appear as areas of high attenuation

• • Very high levels of β-hCG
CECT
o Avid contrast enhancement is seen in peripheral • Differentiation is very difficult in majority of cases, and
oo
nongestational type can be accurately diagnosed only

solid component of mass in prepubertal period
o Enlarged irregular arterial vessels may be seen at
periphery of mass during arterial phase Ectopic Pregnancy
eb
o Peritoneal thickening &/or peritoneal implants may • Presence of adnexal mass, empty uterus, and elevated
be present β-hCG level usually suggests ectopic pregnancy rather
o Ascites may be present occasionally than ovarian nongestational choriocarcinoma
://
o Distant metastases (lung, liver, brain) may be present o If adnexal mass is definitely separate from ovary,
at diagnosis then it is most likely tubal ectopic pregnancy
tp
MR Findings Other Malignant Germ Cell Tumors

• T1WI • Dysgerminoma
ht
o Pelvic mass of predominantly low signal intensity o Typically, large solid mass containing multiple
o High signal intensity areas are suggestive of fibrovascular septa
hemorrhage o May contain calcifications
• T2WI • Yolk sac tumor
o Solid pelvic mass of mixed signal intensity o Elevated α-fetoprotein levels
▪ Low signal intensity solid component o Prominent intratumoral vessels and peripheral
▪ High signal intensity cystic areas within peripheral strong enhancement are characteristic
solid component
▪ High signal intensity central area representing
Sclerosing Stromal Tumor
necrosis/hemorrhage • Normal β-hCG levels
o Invasion of adjacent organs (e.g., uterus) and pelvic • Characteristic appearances in MR with low signal
side wall invasion may be seen at presentation intensity nodules set against high signal intensity
o Liver metastases may be present at diagnosis stroma, and presence of a thin peripheral rim of low
• T1WI C+ FS signal intensity on T2WI
o Avid gadolinium uptake in peripheral solid portion • Typical appearances on dynamic contrast-enhanced
of mass MR
o Early striking peripheral enhancement with
centripetal progression
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Ovary OVARIAN CHORIOCARCINOMA
o Prolonged enhancement of central portion of lesion • Brain metastases occur in 10-20% of patients and are
the leading cause of death; almost all patient with CNS
• Normal β-hCG levels
involvement have lung metastases
• Preserved, peripherally placed ovarian follicles within Treatment

edematous stroma • Hysterectomy and bilateral oophorectomy
Massive Ovarian Edema • Adjuvant chemotherapy
• Normal β-hCG levels
• Raised inflammatory markers, fever, vaginal discharge DIAGNOSTIC CHECKLIST
• Tubular cystic adnexal lesions with rim enhancement Consider
• Primary nongestational ovarian choriocarcinoma in
PATHOLOGY differential diagnosis of hypervascular ovarian tumor
in absence of uterine or extrauterine pregnancy
General Features o β-hCG level should be obtained
• Associated abnormalities Image Interpretation Pearls
o Intra-/extrauterine pregnancy in case of gestational
type • Vascular adnexal mass containing multiple cystic
o Other ovarian malignant germ cell tumor (OMGCT) cavities in solid portion and central necrosis/
t
components in case of nongestational type hemorrhage
ne
o Mucinous cystadenoma
Gross Pathologic & Surgical Features SELECTED REFERENCES

• Large, unilateral, solid, white mass showing focal
e.
1. Shaaban AM et al: Ovarian malignant germ cell tumors:
necrosis and hemorrhage cellular classification and clinical and imaging features.
Radiographics. 34(3):777-801, 2014
yn
2. Lalwani N et al: Rare, miscellaneous primary ovarian
• Plexiform arrangement of syncytiotrophoblast cells neoplasms: spectrum of cross-sectional imaging. Curr Probl
Diagn Radiol. 41(2):73-80, 2012
with mononucleated, mostly cytotrophoblast cells
3. Peterson CM et al: Teratomas: a multimodality review. Curr
around foci of hemorrhage
bg
• Ovarian cases should be distinguished from metastatic
4.
Probl Diagn Radiol. 41(6):210-9, 2012
Shanbhogue AK et al: Clinical syndromes associated with
gestational choriocarcinoma ovarian neoplasms: a comprehensive review. Radiographics.
o Concomitant or proximate gestation almost always
ko
30(4):903-19, 2010
indicates gestational choriocarcinoma 5. Allen SD et al: Radiology of gestational trophoblastic
o Presence of other germ cell components indicate neoplasia. Clin Radiol. 61(4):301-13, 2006
primary ovarian tumor 6. Koshy M et al: Malignant ovarian mixed germ cell tumour: a
oo
rare combination. Biomed Imaging Interv J. 1(2):e10, 2005

7. Bazot M et al: Imaging of pure primary ovarian
CLINICAL ISSUES choriocarcinoma. AJR Am J Roentgenol. 182(6):1603-4,
2004
eb
Presentation 8. Ozaki Y et al: Choriocarcinoma of the ovary associated with

• Most common signs/symptoms mucinous cystadenoma. Radiat Med. 19(1):55-9, 2001
o Signs and symptoms relating to pelvic mass 9. Simsek T et al: Primary pure choriocarcinoma of the ovary
://
o Amenorrhea in reproductive ages: a case report. Eur J Gynaecol Oncol.

o Isosexual pseudoprecocity in prepubertal girls 19(3):284-6, 1998
10. Sashi R et al: Infantile choriocarcinoma: a case report with
o Bleeding from metastatic deposits
tp
•
MRI, angiography and bone scintigraphy. Pediatr Radiol.
o Elevated serum β-hCG 11. Brammer HM 3rd et al: From the archives of the AFIP.
ht
Malignant germ cell tumors of the ovary: radiologic-

Demographics pathologic correlation. Radiographics. 10(4):715-24, 1990
• Age 12. Grover V et al: Primary pure choriocarcinoma of the ovary.
o Nongestational type occurs in prepubertal girls and Gynecol Obstet Invest. 30(1):61-3, 1990
postmenopausal women 13. Axe SR et al: Choriocarcinoma of the ovary. Obstet Gynecol.
o Gestational type occurs during reproductive years 66(1):111-4, 1985
• Epidemiology
14. Jacobs AJ et al: Pure choriocarcinoma of the ovary. Obstet
Gynecol Surv. 37(10):603-9, 1982
o Rare
o Pure nongestational choriocarcinoma represents
2.1-3.4% of all OMGCTs
• Highly malignant neoplasm showing invasion of pelvic
structures and spread into peritoneal cavity
• Tumor metastasizes via lymphatics and blood stream
• Nongestational type has worse prognosis than
gestational type
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OVARIAN CHORIOCARCINOMA
Ovary
(Left) Axial T2WI MR shows a left
adnexal mass of mixed signal
intensity. Note the presence
of high signal intensity areas
within the peripheral solid
component representing areas
of necrosis and hemorrhage. A
normal right ovary is also
noted. (Right) Sagittal T2WI MR
solid adnexal mass of mixed
signal intensity.
t
ne
e.
yn
patient shows a well-defined,
low signal intensity left adnexal
bg mass . Pathological evaluation
revealed pure nongestational
ko
patient shows a necrotic lung

metastasis in the right lower
lobe. Note the peripheral rim
oo
enhancement . Pathology
showed pure nongestational
eb
://
tp
ht
(Left) Axial T2WI FS MR shows a

large pelvic mass with foci of
high signal intensity. (Right) Axial
patient shows the pelvic mass
with enhancing septations
between small cystic spaces,
giving the mass a honeycomb
appearance.
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Ovary OVARIAN CARCINOID
Key Facts
Terminology • Ovarian epithelial carcinomas
• Monodermal teratoma with differentiation toward • Krukenberg tumor
argentaffin cells • Granulosa cell tumor
• Unilateral • Primary ovarian carcinoid tumors are rare
• Multiple morphological patterns have been described o < 0.1% of all ovarian tumors
o Solid nodule in wall of mature cystic teratoma • Presentation
(60-80%) o Pelvic mass
o Solid ovarian mass o Carcinoid syndrome
o Multilocular cystic mass with solid component o Carcinoid heart disease has also been reported
• Octreotide scan • Most occur in postmenopausal women
o Increased uptake in ovarian carcinoid tumors • ~ 1/3 are associated with typical carcinoid syndrome,
despite absence of metastases
Top Differential Diagnoses • Have malignant potential, but usually show benign
• Malignant transformation in mature cystic teratoma behavior clinically
• Struma ovarii • Treated with total abdominal hysterectomy, bilateral
t
• Metastatic carcinoid tumor
ne
oophorectomy, and omentectomy
e.
yn
presented with palpable pelvic
mass shows a left ovarian
bg
with a large solid component
ko
with large areas of enhancing
solid components. Pathology
oo
confirmed ovarian carcinoid

tumor of mucinous type.
eb
://
tp
ht
(Left) Axial fused SPECT/CT

octreotide scan shows a left
ovarian mass composed
of a cystic component
and a solid component .
(Right) Coronal fused SPECT/
CT octreotide scan in the
same patient shows a left
ovarian mass composed
of a cystic component
and a solid component .
In-111 octreotide scintigraphy
is used for localization of
somatostatin receptor-positive
neuroendocrine tumors.
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Ovary
o Blood flow is present in solid mass or solid
TERMINOLOGY
component
Definitions
• Monodermal teratoma with differentiation toward • Best imaging tool
argentaffin cells
o MR
• Protocol advice
IMAGING o Fat-suppression sequences and gadolinium
administration are essential
General Features
• Best diagnostic clue Nuclear Medicine Findings
o Enhancing solid nodule in wall of mature cystic • Octreotide scan
teratoma or enhancing solid mass o Somatostatin receptor scintigraphy with In-111
• Location diethylenetriamine pentaacetic acid (DTPA)-
o Unilateral octreotide
• Size o Increased uptake in ovarian carcinoid tumors
o Varies in size from microscopic to 20 cm in diameter
• Morphology DIFFERENTIAL DIAGNOSIS
o Multiple morphological patterns have been
t
described Malignant Transformation in Mature Cystic
ne
▪ Solid nodule in wall of mature cystic teratoma Teratoma
(60-80%)
▪ Solid ovarian mass
• Solid enhancing mass due to carcinoid component
in mature cystic teratoma may raise possibility of
▪ Multilocular cystic mass with solid component
e.
CT Findings • Transmural extension and invasion of surrounding
• Solid enhancing nodule in wall of mature cystic
yn
structures are seen in malignant transformation
teratoma • Difficult to differentiate if malignant transformation is
o Fat is present if associated with mature cystic confined to mature cystic teratoma without transmural
extension
teratoma
bg
• Solid enhancing mass or multilocular cystic mass with Struma Ovarii
solid component
o Necrosis is rare
• Soft tissue component of struma ovarii contains
ko
thyroid tissue and will avidly enhance
o Calcification may be present
Metastatic Carcinoid Tumor
MR Findings • Usually bilateral solid ovarian masses
• T1WI
oo
o Low signal intensity soft tissue nodule in wall of

• Extraovarian metastases may be present
high signal intensity fat-containing lesion when Granulosa Cell Tumor
• Usually solid in nature
eb
associated with mature cystic teratoma

o Low signal intensity solid mass • Can be difficult to distinguish on imaging, and
▪ Mucinous types show intermediate signal intensity immunohistochemistry is required
•
://
T1WI FS
o Fatty component, if present, demonstrates Krukenberg Tumor
• Evidence of primary GI tumor is usually present
• Usually bilateral ovarian masses
suppressed signal intensity
tp
• T2WI
o Intermediate signal intensity soft tissue nodule in Ovarian Epithelial Carcinomas
• Mixed cystic and solid ovarian masses with peritoneal
ht
wall of high signal intensity fat-containing lesion

when associated with mature cystic teratoma implants and ascites
o Intermediate signal intensity solid mass
▪ Mucinous carcinoid can show higher signal
intensity than other solid ovarian tumors because PATHOLOGY
they contain high signal intensity mucin General Features
▪ Differentiation from other solid malignant ovarian
tumors may be difficult • Associated abnormalities
o 15% have mature cystic teratoma or mucinous tumor
• T1WI C+
in contralateral ovary
o Variable enhancement of solid mass or solid
component Gross Pathologic & Surgical Features
Ultrasonographic Findings • 60-80% are components of mature cystic teratoma
• Grayscale ultrasound • Appear as firm yellow-tan colored nodule in wall of
o Solid nodule in wall of fat-containing cystic mass mature cystic teratoma or mucinous tumor
o Solid mass, which may contain areas of necrosis • May have cystic spaces
• Color Doppler
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Ovary OVARIAN CARCINOID
Microscopic Features – In contrast with intestinal carcinoids, which

• Carcinoids can be classified according to their present with carcinoid syndrome only when
they develop liver metastases
microscopic appearance into 5 patterns
o Insular (islet cells) carcinoids (~ 50% ) – Ovarian carcinoids drain directly into systemic
▪ Has typical appearance of midgut carcinoids circulation, bypassing liver, which inactivates
– Small acini and solid nests of uniform polygonal serotonin produced by intestinal tumors
cells with abundant cytoplasm and round or oval o Carcinoid heart disease has also been reported
centrally located hyperchromatic nuclei Demographics
– Cytoplasm may contain red, brown, or orange
argentaffin granules
• Age
o Most occur in postmenopausal women
– Connective tissue surrounding cell nests
is commonly dense and hyalinized due to • Epidemiology
o Primary carcinoid tumors are rare
fibrogenic effect of serotonin produced by tumor
▪ Considered malignant, but they are slow growing ▪ < 0.1% of all ovarian tumors
▪ < 5% of ovarian teratomas
and only occasionally associated with metastases
o Trabecular carcinoids (~ 33% ) ▪ ~ 0.5% of all carcinoid tumors
▪ Composed of long wavy trabeculae; cells form Natural History & Prognosis
1 or 2 cell layers surrounded by dense fibrous
connective tissue stroma
• Although ovarian carcinoids have malignant potential,
t
they usually show benign behavior clinically
o Strumal carcinoids (~ 16% )
ne
▪ Composed of thyroid follicles; these follicles Treatment
contain colloid that has merged with cords of • Total abdominal hysterectomy, bilateral oophorectomy,
neoplastic cells in dense fibrous stroma, similar to and omentectomy
e.
trabecular carcinoid
o Mucinous carcinoids (~ 1% )
▪ Composed of small glands or acini with narrow
yn
lumina, lined by uniform columnar or cuboidal Image Interpretation Pearls
epithelium • Majority of ovarian carcinoids appear as solid
– Cells contain small round or oval nuclei or
bg component of mature cystic teratoma
appear as goblet cells distended with mucin
▪ Differential for mucinous carcinoid includes a
Krukenberg tumor (immunohistochemistry is
SELECTED REFERENCES
ko
helpful) 1. Petousis S et al: Mature ovarian teratoma with carcinoid

▪ Slightly more aggressive than other ovarian tumor in a 28-year-old patient. Case Rep Obstet Gynecol.
carcinoids 2013:108582, 2013
oo
2. Mordi IR et al: A rare case of ovarian carcinoid causing heart

– Similar to behavior of mucinous carcinoid
failure. Scott Med J. 56(3):181, 2011
tumors of appendix, and metastases may be 3. Takeuchi M et al: Primary carcinoid tumor of the ovary: MR
present at time of initial evaluation imaging characteristics with pathologic correlation. Magn
eb
o Mixed Reson Med Sci. 10(3):205-9, 2011

• Carcinoids demonstrate positive 4. Alotaibi MO et al: Imaging of ovarian teratomas in children:
immunohistochemistry for neuroendocrine markers a 9-year review. Can Assoc Radiol J. 61(1):23-8, 2010
://
(e.g., synaptophysin, NSE, CD56, chromogranin) 5. Choudhary S et al: Imaging of ovarian teratomas:
• No histological features can reliably predict a appearances and complications. J Med Imaging Radiat
Oncol. 53(5):480-8, 2009
malignant course for these tumors; however, the
tp
6. Guney N et al: Primary carcinoid tumor arising in a mature

following features have been noted in malignant cases cystic teratoma of the ovary: a case report. Eur J Gynaecol
o Prominent mitotic activity (> 3 per high power field), Oncol. 30(2):223-5, 2009
ht
conspicuous nucleoli, necrosis, and paucity of acini 7. Gungor T et al: Primary adenocarcinoid tumor of the
ovary arising in mature cystic teratoma. A case report. Eur J
Gynaecol Oncol. 30(1):110-2, 2009
CLINICAL ISSUES 8. Diaz-Montes TP et al: Primary insular carcinoid of the ovary.
Gynecol Oncol. 101(1):175-8, 2006
Presentation
9. Netea-Maier RT et al: Virilization due to ovarian
androgen hypersecretion in a patient with ectopic
o Pelvic mass adrenocorticotrophic hormone secretion caused by a
o Can be an incidental finding carcinoid tumour: case report. Hum Reprod. 21(10):2601-5,
10.
2006
Kopf B et al: Locally advanced ovarian carcinoid. J Exp Clin
o Small percentage present with symptoms of estrogen
Cancer Res. 24(2):313-6, 2005
or androgen excess (abnormal uterine bleeding or 11. Athavale RD et al: Primary carcinoid tumours of the ovary. J
virilization) Obstet Gynaecol. 24(1):99-101, 2004
o Carcinoid syndrome 12. Outwater EK et al: Ovarian teratomas: tumor types and
▪ ~ 1/3 of ovarian carcinoids are associated with imaging characteristics. Radiographics. 21(2):475-90, 2001
typical carcinoid syndrome, despite absence of 13. Soga J et al: Carcinoids of the ovary: an analysis of 329
metastases reported cases. J Exp Clin Cancer Res. 19(3):271-80, 2000
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Ovary
(Left) Axial CECT shows a central
pelvic mass, which contains
a fat-attenuation component
and an enhancing solid
nodule arising from the
posterior wall. (Right) Axial
shows a right ovarian mass
with predominantly high signal
intensity contents and a posterior
soft tissue component that is
isointense to the pelvic skeletal
muscles.
t
ne
e.
yn
(Left) Sagittal T1WI MR in the
same patient shows a pelvic
mass of predominantly very high
bg signal intensity , suggestive
of fat. Note the presence of
a low signal intensity nodule
arising from the posterior wall
ko
of the mass . (Right) Sagittal

T1 C+ FS MR in the same
patient shows loss of signal of
oo
the large anterior component

following fat suppression,
confirming the presence of fat in
a mature cystic teratoma. Note
eb
moderate enhancement of the

solid component .
://
tp
ht
(Left) Longitudinal
transabdominal color Doppler
ultrasound shows a solid adnexal
mass with moderate internal
vascularity. (Right) Axial CECT in
heterogeneous predominantly
solid pelvic mass , which
contains large area of necrosis
. Pathology confirmed ovarian
carcinoid tumor.
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Key Facts
• Classified as ovarian malignant germ cell tumor • Staged according to TNM and FIGO staging systems
(OMGCT) • Mixed germ cell tumors are composed of more than 1
germ cell element, mainly dysgerminoma, teratoma,
Imaging
• Usually unilateral
and yolk sac tumor (YST)
• Usually very large masses, averaging 17 cm Clinical Issues

• Predominantly solid tumors containing areas of • Extremely rare
extensive necrosis and hemorrhage • Most present in 2nd or 3rd decades
• Fat or calcifications may be seen if immature teratoma • Serum β-hCG levels may be elevated in patients with
element is present in mixed OMGCT elements of choriocarcinoma
Top Differential Diagnoses • Serum AFP levels may be elevated in patients with
• Dysgerminoma
elements of YST
• Highly malignant neoplasms, locally aggressive
• Ovarian torsion • Treatment
• Sex cord-stromal tumors o Surgical resection
• Solid ovarian tumors
t
• Ovarian epithelial neoplasms
ne
e.
yn
girl shows a large mass of
bg
with displacement of the
right kidney. (Right) Axial
ko
shows a large heterogeneously
enhancing predominantly
solid mass . Pathological
evaluation revealed a mixed
oo
germ cell tumor composed of

immature teratoma and yolk
sac elements.
eb
://
tp
ht

abdominal distension shows
a left-sided predominantly
solid ovarian mass . Areas
of small cystic change are
seen within the mass .
Soft tissue masses within the
pelvis represent peritoneal
shows omental caking
and large volume ascites
revealed a mixed germ
cell tumor composed of
dysgerminoma, embryonal
carcinoma, and yolk sac
5 elements.
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OVARIAN MIXED GERM CELL TUMOR, EMBRYONAL CARCINOMA AND POLYEMBRYOMA
Ovary
Definitions Dysgerminoma
• Classified as ovarian malignant germ cell tumor • More commonly appear as solid mass with lobulated
(OMGCT) appearance
• Lobules are separated by enhancing septa
IMAGING • Can be very difficult to distinguish on imaging alone
General Features Ovarian Torsion
• Best diagnostic clue • Typical clinical presentation with acute pelvic pain
o Predominantly solid tumors containing areas of • Smaller size of mass
extensive necrosis and hemorrhage • Multiple small peripheral follicles displaced due to
• Location edematous stroma
• Twisted vascular pedicle
• Size Sex Cord-Stromal Tumors
o Usually very large masses, averaging 17 cm
• Granulosa cell and Sertoli-Leydig tumors may occur as
• Morphology predominantly solid tumors in young females but have
o Large, solid mass with extensive necrosis and distinct associated endocrine effects
t
hemorrhage
Solid Ovarian Tumors
ne
CT Findings • Fibroma and fibrothecoma usually occur in older age
• Large, complex, enhancing solid pelvic mass group
• Low-attenuation areas represent extensive necrosis • Typical low signal intensity on T2WI
e.
• High- or low-attenuation areas may also represent Ovarian Epithelial Neoplasms
hemorrhage
• Fat or calcifications may be seen if immature teratoma • Predominantly cystic lesions that occur in middle-aged
yn
or older women
element is present in mixed OMGCT
• Extensive peritoneal disease and ascites are usually
MR Findings
bgpresent at diagnosis
• T1WI • Hematogenous metastases are rare
o Low or intermediate signal intensity mass that may
contain areas of high signal intensity representing
ko
PATHOLOGY
hemorrhage
• T2WI Staging, Grading, & Classification
o Large mass of predominantly high signal intensity • Staged according to TNM and FIGO staging systems
oo
due to extensive necrosis

• T1WI C+ FS Gross Pathologic & Surgical Features
o Avid enhancement of solid portions of tumor • Smooth outer surface
• Solid and soft, with highly variegated appearance and
eb
o Peritoneal thickening &/or implants, if present, are

best appreciated on delayed gadolinium-enhanced extensive areas of hemorrhage and necrosis
images • Cystic spaces that contain mucoid material
• Appearance varies according to number and types of
://
Ultrasonographic Findings components present in mixed tumors

• Grayscale ultrasound • Polyembryomas may have a microcystic cut surface
tp
o Predominantly solid heterogeneous adnexal mass

o Anechoic cystic areas represent necrosis and • Macroscopic fat and calcifications may be seen in
mixed tumors with teratomatous elements
ht
hemorrhage
o Ascites and peritoneal implants may be present Microscopic Features
• Color Doppler • Mixed germ cell tumors
o Marked blood flow within solid components o Composed of more than 1 germ cell element, mainly
dysgerminoma, teratoma, and yolk sac tumor (YST)
Imaging Recommendations ▪ Other elements (such as choriocarcinoma,
• Best imaging tool polyembryoma, and embryonal carcinoma) may be
o US for initial diagnosis present
o CT/MR for lesion characterization and evaluation of
• Embryonal carcinoma
local extent of tumor o May occur in pure form or as component of mixed
o CT for evaluation of hematogenous metastases
germ cell tumor
▪ e.g., lung, liver ▪ Most common components associated with
• Protocol advice embryonal carcinomas in mixed germ cell tumors
o Transabdominal ultrasound is a must as these are YSTs and dysgerminomas
tumors are usually very large and may be missed on o Typically composed of solid sheets and nests of
transvaginal ultrasound alone large primitive cells in pseudoglandular pattern that
occasionally form papillae
5
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o Nuclei are large, crowded, pleomorphic, and

vesicular, with prominent nucleoli
• Polyembryomas Consider
o Small embryo-like bodies with central “germ discs” • Malignant germ cell tumor of ovary should be
that are composed of embryonal carcinoma epithelia considered when large, predominantly solid ovarian
and 2 cavities tumor is discovered in girl or young woman
▪ Dorsal cavity that resembles amniotic cavity and
• Predominantly solid tumor with extensive necrosis and
ventral cavity that resembles yolk sac
o Embryoid bodies lie in edematous to myxoid stroma
hemorrhage
that has prominent blood vessels

1. Shaaban AM et al: Ovarian malignant germ cell tumors:
Presentation cellular classification and clinical and imaging features.
• Most common signs/symptoms Radiographics. 34(3):777-801, 2014
o Abdominal or pelvic mass 2. Peterson CM et al: Teratomas: a multimodality review. Curr
o 2/3 have hormonal manifestations Probl Diagn Radiol. 41(6):210-9, 2012
3. Moniaga NC et al: Malignant mixed ovarian germ cell tumor
▪ Precocious pseudopuberty
with embryonal component. J Pediatr Adolesc Gynecol.
▪ Uterine bleeding
t
•
24(1):e1-3, 2011
ne
Other signs/symptoms 4. Cicin I et al: Malignant ovarian germ cell tumors: a single-
o Serum β-hCG levels may be elevated in patients with institution experience. Am J Clin Oncol. 32(2):191-6, 2009
elements of choriocarcinoma 5. De Backer A et al: Ovarian germ cell tumors in children:
o Serum AFP levels may be elevated in patients with a clinical study of 66 patients. Pediatr Blood Cancer.
e.
46(4):459-64, 2006
elements of YST
6. Baker PM et al: Immunohistochemistry as a tool in the
Demographics
yn
differential diagnosis of ovarian tumors: an update. Int J
• Age 7.
Gynecol Pathol. 24(1):39-55, 2005
Ulbright TM: Germ cell tumors of the gonads: a selective
o Most present in 2nd or 3rd decades
review emphasizing problems in differential diagnosis,
o Median age: 15 years
bg newly appreciated, and controversial issues. Mod Pathol. 18
• Epidemiology Suppl 2:S61-79, 2005
o Mixed germ cell tumors 8. Ulbright TM: Gonadal teratomas: a review and speculation.
▪ 1.7-5.3% of all OMGCT Adv Anat Pathol. 11(1):10-23, 2004
ko
o Embryonal carcinomas 9. Nishida T et al: Ovarian mixed germ cell tumor comprising
▪ 4.1-4.7% of all OMGCT polyembryoma and choriocarcinoma. Eur J Obstet Gynecol
Reprod Biol. 78(1):95-7, 1998
▪ Pure ovarian embryonal carcinomas are extremely
oo
10. Borghi A et al: [An ovarian mass in childhood: a case report]

rare Pediatr Med Chir. 15(4):413-5, 1993
– Usually found as component of mixed germ cell 11. Brammer HM 3rd et al: From the archives of the AFIP.
tumor Malignant germ cell tumors of the ovary: radiologic-
eb
o Polyembryoma: Extremely rare pathologic correlation. Radiographics. 10(4):715-24, 1990

▪ Few cases have been reported in English medical 12. Kawai M et al: Alpha-fetoprotein in malignant germ cell
literature, none of which were in a pure form but tumors of the ovary. Gynecol Oncol. 39(2):160-6, 1990
://
13. Ueda G et al: Embryonal carcinoma of the ovary: a six-year

rather as component of mixed OMGCTs
survival. Int J Gynaecol Obstet. 31(3):287-92, 1990
– Immature teratomas and YSTs are most
commonly reported components associated with
tp
polyembryoma in mixed germ cell tumors

ht
• Highly malignant neoplasms, locally aggressive

• Presence of highly malignant elements, such as YST
and high-grade immature teratoma, are associated with
more aggressive behavior
• Spread widely within peritoneal cavity
• Metastasis to lungs, liver, and retroperitoneal lymph
nodes
Treatment
• Surgical resection
• Adjuvant chemotherapy &/or radiotherapy
5
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Ovary
an abdominal mass and was
found to have high levels of
α-fetoprotein (AFP) shows a
filling the pelvic cavity. (Right)
shows a large solid pelvic mass
. Areas of fat attenuation
are present within the
mass. Pathological evaluation
revealed a mixed germ cell tumor
composed of dysgerminoma,
immature teratoma, and yolk sac
elements.
t
ne
e.
yn
abdominal mass shows a large
bg heterogeneous solid mass
with no evidence of calcifications
or fat attenuation. Omental
nodularities are present
ko
due to peritoneal metastases.

same patient shows a solid
oo
abdominopelvic mass .
Omental nodularities and
a small amount of perihepatic
ascites are present. Pathological
eb
evaluation revealed a mixed

germ cell tumor composed
of dysgerminoma, embryonal
carcinoma, and yolk sac
://
elements.
tp
ht

old girl who presented with an
abdominal mass and was found
to have elevated AFP levels
solid mass within the right
abdomen/pelvis. Areas of
cystic change are present.
abdominopelvic mass with
scattered foci of calcification
revealed a mixed germ cell tumor
composed of immature teratoma
and yolk sac elements.
5
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Key Facts
Terminology o Multilocular cystic lesion with loculi showing
• Monodermal teratoma in which thyroid tissue is variable signal intensities
o Some loculi show very low signal intensity on T2WI
exclusively present or constitutes > 50% of mature
cystic teratoma • US
o Multilocular cystic tumors containing "struma
Imaging pearls"
• Multilocular cystic mass with avidly enhancing soft • Uptake in mass on I-123 imaging
tissue component ± dermoid cyst
• Other recognized patterns include Top Differential Diagnoses
o Multilocular cystic mass without solid component • Mature cystic teratoma
o Predominantly solid tumor with small cystic spaces • Mucinous cystadenoma
o Unilocular cystic lesion • Mucinous cystadenocarcinoma
• CT
Clinical Issues
o High-density cysts
o Solid component shows high density and strong • Most cases are asymptomatic
enhancement • 5-15% have associated hyperthyroidism
• MR • Presents during reproductive years
t
• 95% cases are benign with very good prognosis
ne
e.
yn
ultrasound shows a
multilocular cystic ovarian
mass with multiple,
bg
echogenic, rounded intracystic
"struma pearls" ,a
characteristic sonographic
ko
feature of struma ovarii. These
struma pearls tend to be
well vascularized. (Right)
Axial transvaginal ultrasound
oo
shows a multilocular cystic

mass with 1 locule almost
anechoic , while the 2nd
eb
locule is of heterogeneous
echogenicity with a solid
echogenic component
containing a small cystic space
://
.
tp
ht
(Left) Axial NECT shows a

right ovarian mass composed
predominantly of a large, solid
component of high signal
intensity (70 HU) . There
is a small anterior rim of fat
density within the lesion.
This is an example of impure
struma ovarii where thyroid
tissue constitutes the majority
of tissues in a dermoid cyst.
mass. One of the loculi shows
relative high density , and
there is an intensely enhancing
solid mass .
5
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Ovary
o Multilocular cystic lesion with loculi showing
TERMINOLOGY
variable signal intensities
Definitions o Punctuate foci of high signal intensity in or adjacent
• Example of monodermal ovarian teratoma to thickened septa, cyst walls, or solid mass
o Monodermal teratomas are defined as teratomas ▪ High signal intensity foci are not suppressed on fat-
composed predominantly or solely of single tissue suppression images in majority of cases
type o Signal intensity of solid components is intermediate
▪ Examples include struma ovarii (most common), or slightly hyperintense in most cases
carcinoid, and neural tumors • T2WI
• Occurs when thyroid tissue is exclusively present or o Multilocular cystic lesions with most loculi showing
constitutes > 50% of mature cystic teratoma high signal intensity
▪ Those loculi showed various signal intensities from
low to high on corresponding T1WI
IMAGING o Some loculi show very low signal intensity
General Features ▪ Those loculi show variable signal intensity on
• Best diagnostic clue T1WI (low, intermediate or slightly high)
▪ No enhancement of these loculi on T1W C+ FS
o Multilocular cystic mass with avidly enhancing soft
images
tissue component ± dermoid cyst
o Signal intensity of solid components is low to
•
t
Location
intermediate in majority of cases
ne
o Usually unilateral tumor
▪ High signal intensity may occasionally be seen in
• Size
solid component
o Vary in size but usually measure < 10 cm in diameter
o If associated with hyperthyroidism, struma ovarii • T1WI C+ FS
e.
o Strong enhancement of solid components after
generally > 6 cm in diameter
• Morphology
gadolinium
yn
o Most common pattern is multilocular cystic mass Ultrasonographic Findings
with lobulated surface and some solid components • Grayscale ultrasound
▪ Represents thyroid tissue with markedly dilated o Multilocular cystic mass with lobulated surface and
bg
thyroid follicles some solid components
o Other recognized patterns include o Other patterns have been described
▪ Multilocular cystic mass without discernible solid ▪ Cystic tumors containing 1 or more well-
ko
component circumscribed, rounded, solid areas with smooth

– Can mimic benign cystic ovarian epithelial contours; "struma pearls"
neoplasm ▪ Multilocular cystic mass without discernible solid
oo
▪ Predominantly solid tumor with small cystic component; can mimic benign cystic ovarian
spaces neoplasm
▪ Unilocular cystic lesion ▪ Solid tumors with heterogeneous internal
o Impure struma ovarii
eb
echogenicity and containing cystic spaces

▪ Struma ovarii as part of dermoid cyst o Cyst fluid is always anechoic or of low-level
– Imaging findings of dermoid cyst: Fat, echogenicity
calcifications, and teeth o Impure struma ovarii
://
o Malignant struma ovarii ▪ May be indistinguishable from benign dermoid

▪ No specific imaging features are available to detect cyst
tp
malignant struma – Cystic mass containing echogenic "dermoid

▪ CT and MR imaging findings of malignant plug" or "tip of iceberg"
transformation ▪ May also show any of the patterns described with
ht
– Invasive growth pattern with irregular soft tissue pure struma ovarii ± features of benign dermoid
mass showing transmural extension cyst
CT Findings • Color Doppler
o Most tumors moderately vascularized
• NECT ▪ Varies between no and abundant flow
o Multilocular cystic mass with solid component
o "Struma pearls" tend to be vascularized
▪ Some loculi shows high attenuation
– High-density cysts with CT values ranging from Nuclear Medicine Findings
58 to 98 HU • PET/CT
▪ Solid component shows high attenuation due to o No increased metabolic activity was seen in the few
iodine contents within thyroid tissue reported cases
▪ Calcifications may be present within solid nodule, • Scintigraphy
within wall, or in septa o Using either I-123 or I-131
• CECT o Useful for diagnosing hyperfunctioning struma
o Strong enhancement of solid component ovarii on the basis of higher uptake of radionuclide
MR Findings by ovarian mass compared with thyroid gland
• T1WI 5
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Imaging Recommendations • Cut surface is soft or firm, red-brown in color, and may
• Best imaging tool have areas of hemorrhage or necrosis
o MR imaging • Thyroid nodules may be extruded from ovarian lesion
• Protocol advice and seeded on peritoneum and omentum
o Gives rise to condition known as benign strumosis
o Post-gadolinium imaging is essential
ovarii which may erroneously be interpreted as
manifestation of malignant ovarian struma
Mature Cystic Teratoma • Composed of mature thyroid tissue consisting of
• Fat-containing mass with peripheral blood flow and colloid-containing follicles of various sizes lined by
avascular central mass (floating Rokitansky nodule on single layer of follicular cells
fat-fluid interface) • Can also show range of pathological changes such as
colloid goiter, hyperplasia, and rarely, papillary thyroid
Mucinous Cystadenoma carcinoma
• Multicystic ovarian mass with thin septations forming • Immunohistochemistry is positive for thyroglobulin
multiple locules and chromogranin
• Locules have different densities on CT or different • Malignant transformation is uncommon; only about
signal intensities on MR reflecting various 5% of struma ovarii are malignant
concentrations of mucin o In many malignant cases there is only small focus of
t
ne
Mucinous Cystadenocarcinoma malignancy
o Metastases are found in 5–6% of patients with
• Malignant ovarian neoplasm that differs from benign malignant struma ovarii
counterpart by presence of heterogeneous solid
e.
component
• Peritoneal and serosal implants are usually present at CLINICAL ISSUES
time of presentation
yn
Presentation
Thyroid Cancer Metastases to Ovary
• Exceedingly rare • Most common signs/symptoms
o Most cases are asymptomatic
• Widespread metastatic disease should be documented
bg
o Abdominal distension, pain, urinary or intestinal
to consider secondary thyroid neoplasm of ovary obstruction, infertility, or hot flashes (the latter a
result of steroid hormone production)
ko
PATHOLOGY o Occasionally, patients present with ascites or with

both ascites and pleural effusion (pseudo-Meigs
General Features syndrome)
oo
▪ Benign struma ovarii may be associated with

o May be associated with mature cystic teratoma in ascites in up to 17% of cases
same or contralateral ovary o Infrequently associated with thyrotoxicosis
o Strumal carcinoid •
eb
▪ Unique tumor that is characterized by presence of o 5-15% have associated hyperthyroidism
both carcinoid and thyroid tissue within struma o Occasionally, tumor marker CA125 can be elevated
ovarii
://
▪ Clinical manifestations of hyperandrogenism or Demographics

hyperestrogenism (8%) and hyperthyroidism (8%) • Age
o Most patients are in their reproductive years
tp
▪ Occurrence of associated carcinoid syndrome is

rare ▪ May be diagnosed at any age, even in children
o Small percentage are associated with mucinous • Epidemiology
ht
cystadenomas or Brenner tumor in same ovary o ~ 3% of all ovarian teratomas

o ~ 2% of all germ cell tumors of ovary
Staging, Grading, & Classification o ~ 0.5% of all ovarian tumors
• Malignant struma ovarii is staged as epithelial ovarian
carcinoma using either FIGO or TNM staging system Natural History & Prognosis
Gross Pathologic & Surgical Features • 95% cases are benign and with very good prognosis
• Smooth external wall • < 5% of struma ovarii cases are malignant
o Most commonly follicular carcinoma, papillary
• Can be solid, mixed cystic–solid, or entirely cystic
• Partially cystic and solid loculated mass filled with
carcinoma, or mixed pattern (similar to types of
thyroid carcinoma)
gelatinous material
• Usually seen as circumscribed nodules in wall of mature • Malignant struma ovarii rarely metastasizes
o When metastatic, spreads first by peritoneal
teratoma
implantation and subsequently by hematogenous
spread to bone, liver, brain, and lungs
5
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STRUMA OVARII
Ovary
o Metastasis can appear many years after resection of 15. Cherng SC et al: Malignant struma ovarii with peritoneal
primary tumor implants and pelvic structures and liver metastases
• Metastatic spread from thyroid carcinoma to ovary is demonstrated by I-131 SPECT and low-dose CT. Clin Nucl
Med. 30(12):797-8, 2005
exceedingly rare
16. Garcia A et al: Malignant struma ovarii mimic clear cell
o Should not be considered unless there is history of
carcinoma. Arch Gynecol Obstet. 271(3):251-5, 2005
primary thyroid carcinoma 17. Ciccarelli A et al: Thyrotoxic adenoma followed by atypical
hyperthyroidism due to struma ovarii: clinical and genetic
Treatment
• Struma ovarii is treated by oophorectomy
studies. Eur J Endocrinol. 150(4):431-7, 2004
18. Utsunomiya D et al: Struma ovarii coexisting with mucinous
• Pelvic clearance, thyroidectomy, and radioactive iodine cystadenoma detected by radioactive iodine. Clin Nucl Med.
is recommended for malignant tumors 28(9):725-7, 2003
o Post-treatment follow-up is accomplished by serial 19. Van de Moortele K et al: Struma ovarii: US and CT findings.
serum thyroglobulin levels JBR-BTR. 86(4):209-10, 2003
20. Huh JJ et al: Struma ovarii associated with pseudo-Meigs'
syndrome and elevated serum CA 125. Gynecol Oncol.
21. Robboy SJ et al: Pathology of the Female Genital Tract. 1st
Consider ed. London: Harcourt. 672-4, 2002
• Check serum thyroid function values in patient 22. Outwater EK et al: Ovarian teratomas: tumor types and
imaging characteristics. Radiographics. 21(2):475-90, 2001
with teratoma-appearing ovarian mass that shows
t
considerable enhancement of solid components on CT 23. Emoto M et al: Transvaginal color Doppler ultrasonic
ne
characterization of benign and malignant ovarian cystic
and MR, and demonstrates low-resistance arterial flow
teratomas and comparison with serum squamous cell
on US
•
carcinoma antigen. Cancer. 88(10):2298-304, 2000
Consider malignant struma ovarii in presence of 24. Kim JC et al: MR findings of struma ovarii. Clin Imaging.
e.
irregular soft tissue component with extension beyond 24(1):28-33, 2000
tumor capsule and invasion of surrounding structures 25. Matsuki M et al: Struma ovarii: MRI findings. Br J Radiol.
73(865):87-90, 2000
yn
Image Interpretation Pearls 26. Okada S et al: Cystic struma ovarii: imaging findings. J
• Look for intense enhancement of central solid Comput Assist Tomogr. 24(3):413-5, 2000
component within teratoma, as thyroid tissue is highly 27. Zalel Y et al: Sonographic and clinical characteristics of
vascular
bg struma ovarii. J Ultrasound Med. 19(12):857-61, 2000
• Multicystic variant is radiographically 28. Joja I et al: I-123 uptake in nonfunctional struma ovarii. Clin
Nucl Med. 23(1):10-2, 1998
indistinguishable from mucinous cystadenoma
29. Joja I et al: Struma ovarii: appearance on MR images. Abdom
ko
Imaging. 23(6):652-6, 1998

SELECTED REFERENCES 30. Dohke M et al: Struma ovarii: MR findings. J Comput Assist
Tomogr. 21(2):265-7, 1997
1. Dujardin MI et al: Struma ovarii: role of imaging? Insights
oo
31. Yamashita Y et al: Struma ovarii: MR appearances. Abdom

Imaging. 5(1):41-51, 2014 Imaging. 22(1):100-2, 1997
2. Koo PJ et al: SPECT/CT of metastatic struma ovarii. Clin 32. Zalel Y et al: Doppler flow characteristics of dermoid cysts:
Nucl Med. 39(2):186-7, 2014 unique appearance of struma ovarii. J Ultrasound Med.
eb
3. Nurliza Binti Md Nor et al: Three cases of struma ovarii 16(5):355-8, 1997
underwent laparoscopic surgery with definite preoperative 33. Brenner W et al: Radiotherapy with iodine-131 in recurrent
diagnosis. Acta Med Okayama. 67(3):191-5, 2013 malignant struma ovarii. Eur J Nucl Med. 23(1):91-4, 1996
4. Poncelet E et al: Value of dynamic contrast-enhanced MRI 34. Matsumoto F et al: Struma ovarii: CT and MR findings. J
://
for tissue characterization of ovarian teratomas: correlation Comput Assist Tomogr. 14(2):310-2, 1990
with histopathology. Clin Radiol. 68(9):909-16, 2013
5. Ikeuchi T et al: CT and MR features of struma ovarii. Abdom
tp
Imaging. 37(5):904-10, 2012

6. Khashper A et al: T2-hypointense adnexal lesions: an
ht

7. Shen J et al: Diagnosis of Struma ovarii with medical
imaging. Abdom Imaging. 36(5):627-31, 2011
8. Shanbhogue AK et al: Clinical syndromes associated with
ovarian neoplasms: a comprehensive review. Radiographics.
30(4):903-19, 2010
9. Saba L et al: Mature and immature ovarian teratomas: CT, US
and MR imaging characteristics. Eur J Radiol. 72(3):454-63,
2009
10. Jung SI et al: Struma ovarii: CT findings. Abdom Imaging.
33(6):740-3, 2008
11. Park SB et al: Imaging findings of complications and unusual
manifestations of ovarian teratomas. Radiographics.
28(4):969-83, 2008
12. Savelli L et al: Imaging of gynecological disease (4): clinical
and ultrasound characteristics of struma ovarii. Ultrasound
Obstet Gynecol. 32(2):210-9, 2008
13. Yoo SC et al: Clinical characteristics of struma ovarii. J
Gynecol Oncol. 19(2):135-8, 2008
14. McDougall IR: Metastatic struma ovarii: the burden of truth.
Clin Nucl Med. 31(6):321-4, 2006 5
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Ovary STRUMA OVARII

with abdominal pain shows
a cystic mass with an
. (Right) Axial CECT in
bilocular cystic mass with
an enhancing solid component
within the septum
dividing the 2 cystic locules.
Pathological examination
revealed a pure struma ovarii
with 2 colloid-filled cysts.
Microscopic foci of follicular
carcinoma were detected
t
within the thyroid tissue.
ne
e.
yn
with high attenuation within
bg
the cystic loculi (65 HU).
There is a solid enhancing
component representing
ko
thyroid tissue and fat density

elements representing
components of a mature cystic
oo
teratoma in an impure struma

ovarii. (Right) Coronal CECT
high-density cystic loculi
eb
and the central enhancing

solid component .
://
tp
ht

predominantly fat-filled
left ovarian mass with
an avidly enhancing solid
component containing
foci of calcification .
same patient shows the fat-
filled mass and the avidly
. The presence of an
enhancing mural nodule in
a mature cystic teratoma
does not necessarily indicate
malignancy, but may be due to
enhancing thyroid elements, as
in this case, or other epithelial
5 components.
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STRUMA OVARII
Ovary
with a palpable abdominal mass
shows a multilocular cystic mass
with thick septa and
peripheral soft tissue nodules
of heterogeneous signal intensity.
The uterus is displaced
anteriorly. (Right) Axial T2WI MR
in the same patient demonstrates
a multilocular cystic mass ,
with the loculi showing variable
signal intensities.
t
ne
e.
yn
the same patient again shows
the ovarian mass . The
bg cystic components are of low
signal intensity and the solid
component shows signal
intensity similar to that of the
ko
pelvic skeletal muscle. (Right)

oo
enhancement of the peripheral

solid nodules and mild septal
enhancement .
eb
://
tp
ht

same patient again demonstrates
an ovarian mass . The
cystic components show
low signal intensity and the
solid component has a
signal intensity similar to that
of pelvic skeletal muscle.
enhancement of the peripheral
solid component as well as
septal enhancement .
5
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Ovary GRANULOSA CELL TUMOR
Key Facts
Terminology • Fibroma/fibrothecoma
• Classified as sex cord-stromal tumor Pathology
• 2 subtypes: Adult and juvenile • Most common (80%) ovarian neoplasm associated
Imaging with symptoms related to overproduction of female sex
• Large solid and cystic adnexal mass hormones (estrogenic manifestations)
• Almost always unilateral Clinical Issues

• Different patterns have been described • ~ 60% in postmenopausal women
o Multilocular cystic lesions with solid components • Account for 3-5% of all malignant ovarian tumors
o Solid masses
• Potential for clinically malignant behavior
o Solid with a sponge-like "Swiss cheese" appearance
o Cystic tumors with thick rind of soft tissue
• Single most important prognostic factor is disease stage
at presentation
• Enlarged uterus with endometrial thickening • Radical surgery (total abdominal hysterectomy
and bilateral salpingo-oophorectomy) is preferred
• Mucinous or serous cystadenoma or
treatment
cystadenocarcinoma
t
• Hemorrhagic ovarian cyst
ne
e.
yn
ultrasound shows a right
ovarian mass . The mass
is composed of numerous
bg
small cystic spaces separated
by thin septa, giving the
lesion a "Swiss cheese"
ko
appearance. This appearance
closely resembles that of a
hemorrhagic cyst. (Right)
Sagittal transvaginal duplex
oo

ovarian mass with definite
eb
blood flow within the septa

separating the small cystic
spaces.
://
tp
ht

solid right ovarian mass
with a multilocular cystic
shows a heterogeneous but
predominantly solid right
ovarian mass with small
anechoic cysts .
5
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GRANULOSA CELL TUMOR
Ovary
TERMINOLOGY ▪ Solid component → homogeneous or
Abbreviations ▪ Heterogeneous echogenicity may indicate
• Granulosa cell tumor (GCT) hemorrhage, fibrosis, or necrosis
▪ Unilocular and solid appearances are uncommon
Definitions o Thickened endometrial stripe → cystic changes
• Malignant ovarian tumor classified as sex cord-stromal • Color Doppler
tumor o Low resistance vessels in thickened septations or
• 2 subtypes solid component
o Adult: ~ 95% of all GCTs
o Juvenile: ~ 5% of all GCTs PET/CT
• Usually very low FDG avidity
IMAGING
General Features
• Best diagnostic clue Epithelial Ovarian Tumors
o Large solid and cystic adnexal mass and thickened • If tumor presents as multilocular cystic mass with
endometrial stripe thickened septations, differentiation is difficult
• Location o Ovarian endometrioid carcinoma can present
t
o Almost always unilateral as multilocular cystic mass with endometrial
ne
▪ 9% of adult type and 2% of juvenile type are thickening similar to GCT
bilateral • Unilocular cystic mass is a rare presentation of
• Size GCT; more commonly seen in cystadenoma or
e.
o Average: 12.5 cm cystadenocarcinoma
• Morphology • Large GCTs are less likely to have peritoneal spread
yn
o Different patterns have been described than large epithelial tumors
▪ Multilocular cystic lesions with solid components Hemorrhagic Ovarian Cyst
▪ Solid masses • Apparent septations or retracting clot do not show flow
▪ Solid with a sponge-like appearance resembling
bg
on color Doppler
Swiss cheese • Changes or resolves on follow-up
▪ Completely cystic tumors with thick rind of soft
Fibroma/Fibrothecoma
ko
tissue
o Enlarged uterus with endometrial thickening • Solid ovarian mass
CT Findings • May be associated with thickened endometrial stripe
oo
• Solid, enhancing mass with variable cystic or

hemorrhagic/necrotic areas of low attenuation PATHOLOGY
MR Findings General Features
eb
• T1WI • Etiology
o Solid and cystic mass o Believed to arise from cells surrounding germinal
o Cysts may have increased signal intensity due to cells in ovarian follicles
://
hemorrhage • Associated abnormalities

• T2WI o Most common (80%) ovarian neoplasm associated
tp
o Common appearances: Multilocular cystic mass with with estrogenic manifestations

solid components, or solid mass with internal cysts ▪ Manifestations include endometrial hyperplasia,
ht
("Swiss cheese" appearance) glandular hyperplasia, atypical adenomatous

▪ Low signal on T2WI or fluid-fluid levels with hyperplasia, and adenocarcinoma; present in
intracystic hemorrhage 5–25% of cases
▪ Thick septations may have low signal intensity
▪ Uncommon appearances: Unilocular cystic mass or Staging, Grading, & Classification
entirely solid mass • Staged as ovarian carcinoma using FIGO and TNM
o Juvenile type usually solid mass of high signal staging systems
o Enlarged uterus with thickened hyperintense Gross Pathologic & Surgical Features
endometrium • Large, encapsulated tumors with smooth or lobulated
• T1WI C+ surface
o Solid component enhances o Capsule may rupture in 10-15%
o Juvenile type → homogeneous enhancement
• Composed of solid and cystic areas in variable
Ultrasonographic Findings proportions
o Totally cystic lesions are rare
• Grayscale ultrasound • Hemorrhage and necrosis may be seen in larger tumors
o Echogenic, solid ovarian mass with variable amount
of cystic components • Macroscopic appearance of juvenile type is similar to
adult type
▪ Usually multilocular with thick or thin walls and
septations 5
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Microscopic Features o Median time to relapse is 4-6 years after initial

• Adult GCT diagnosis; recurrence reported as late as 37 years
o Composed of at least 10% granulosa cells, often • Adult GCT
embedded in fibrothecomatous stroma o Single most important prognostic factor is disease
o Granulosa cells, the hallmark of GCTs, have round stage at presentation
or ovoid nucleus with longitudinal groove ("coffee ▪ Stage I disease (70-90% of cases at diagnosis)
bean" nuclei) and scant cytoplasm – 5-year survival rate > 90%
o Small round spaces containing eosinophilic fluid ▪ Advanced stage (10-30% of cases at diagnosis)
or pyknotic nuclei (Call-Exner bodies) are seen in – 5-year survival of 33–50%
30-60% of cases • Juvenile GCT → high cure rate
o Mitotic activity is low o Mortality is < 3% if confined to ovary
• Juvenile GCT o Recurrences are uncommon; typically occur in 1st
o Less well differentiated than adult type year and rarely later
o Granulosa cells are larger, have abundant cytoplasm,
Treatment
and nuclear grooves are absent
o Call-Exner bodies are not observed • Radical surgery (total abdominal hysterectomy and
bilateral salpingo-oophorectomy) is preferable
o Mitotic activity is high
• Adult and juvenile granulosa tumor cells are positive
• More conservative unilateral salpingo-oophorectomy
with careful staging and endometrial biopsy is possible
t
for inhibin immunohistochemistry for early stages in those patients who wish to remain
ne
fertile
CLINICAL ISSUES • Limited and inconclusive data regarding value of
adjuvant radiotherapy or systemic chemotherapy due
Presentation
e.
to rarity of tumors and long interval to relapse
• Most common signs/symptoms • Hormonal therapy of recurrent granulosa cell tumors
o Abnormal vaginal bleeding has been successfully reported
yn
▪ Due to endometrial hyperplasia, polyps, &/or o Important to know whether tumor has receptors for
carcinoma estrogen (present in 30%) or progesterone (present in
o Abdominal mass, abdominal pain most cases)
bg
o Isosexual precocious puberty in pediatric population
o 5-15% present with hemoperitoneum and acute
abdominal pain secondary to tumor rupture
SELECTED REFERENCES
ko
o 10% are associated with ascites 1. Stine JE et al: Pre-operative imaging with CA125 is a
o 10% of tumors are clinically occult poor predictor for granulosa cell tumors. Gynecol Oncol.
o Some cases demonstrate pseudo-Meigs syndrome 131(1):59-62, 2013
2. Chung EM et al: From the radiologic pathology archives:
oo
with pleural effusion and ascites

•
precocious puberty: radiologic-pathologic correlation.
Other signs/symptoms Radiographics. 32(7):2071-99, 2012
o ↑ risk of breast cancer, incidence of 3.7-20% 3. Wang Y et al: Childhood ovarian juvenile granulosa cell
o Infertility due to unregulated inhibin secretion
eb
tumor: a retrospective study with 3 cases including clinical

o Androgenic activity may occur (virilization) features, pathologic results, and therapies. J Pediatr Hematol
o ↑ CA125 in < 45% of patients Oncol. 33(3):241-5, 2011
4. Kim JA et al: High-resolution sonographic findings of
://
Demographics ovarian granulosa cell tumors: correlation with pathologic

• Age findings. J Ultrasound Med. 29(2):187-93, 2010
o Wide range (newborn to postmenopausal) 5. Raj G et al: Positron emission tomography and granulosa
tp
cell tumor recurrence: a report of 2 cases. Int J Gynecol

▪ ~ 5% in prepubertal period
Cancer. 19(9):1542-4, 2009
▪ ~ 35% in premenopausal women
ht
6. Van Holsbeke C et al: Imaging of gynecological disease

▪ ~ 60% in postmenopausal women (3): clinical and ultrasound characteristics of granulosa
o Adult GCT cell tumors of the ovary. Ultrasound Obstet Gynecol.
▪ Middle-aged and older women 31(4):450-6, 2008
– Median age: 51 7. Crew KD et al: Long natural history of recurrent granulosa
– 10% present during pregnancy cell tumor of the ovary 23 years after initial diagnosis: a
o Juvenile GCT case report and review of the literature. Gynecol Oncol.
96(1):235-40, 2005
▪ 97% of cases occur in females < 30 years
•
8. Jung SE et al: CT and MRI findings of sex cord-stromal tumor
Epidemiology of the ovary. AJR Am J Roentgenol. 185(1):207-15, 2005
o Incidence of 0.5–1.5 per 100,000 women per year 9. Tanaka YO et al: Functioning ovarian tumors: direct and
o ~ 3-5% of all malignant ovarian tumors indirect findings at MR imaging. Radiographics. 24 Suppl
o Most common sex cord-stromal tumor after fibromas 1:S147-66, 2004
and fibrothecomas 10. Jung SE et al: CT and MR imaging of ovarian tumors
o Most common malignant sex cord-stromal tumor with emphasis on differential diagnosis. Radiographics.
22(6):1305-25, 2002
(70%)
• Potential for clinically malignant behavior
5 • Propensity for late recurrence
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Obgyne Books Full
Ovary
woman shows a right ovarian
mass that is predominantly
solid but with numerous small
cystic spaces, exhibiting a "Swiss
cheese" appearance. (Right)
Doppler ultrasound confirms the
presence of blood flow within
the right ovarian mass . The
"Swiss cheese" appearance
closely resembles that of benign
hemorrhagic cyst, and these 2
entities can only be differentiated
by the presence of septal blood
t
flow in GCTs.
ne
e.
yn
year-old postmenopausal woman
who presented with vaginal
bg bleeding shows a heterogeneous,
hyperintense left ovarian mass
. The mass shows small
cystic components separated
ko
by septa, producing the "Swiss

cheese" appearance. (Right)
oo
patient shows the left ovarian

mass and thickening of the
endometrium, measuring 10 mm.
eb
://
tp
ht

relatively homogeneous left
ovarian mass that is iso- to
hypointense compared to the
pelvic muscles. (Right) Axial
patient shows a left ovarian
mass displaying moderate
enhancement (more than the
myometrium) and containing
small cystic locules. Cystic
changes are also seen within
. Pathological examination
confirmed endometrial
hyperplasia associated with a left
ovarian GCT.
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year-old woman with history
of spina bifida shows a left
ovarian mass composed of
a solid component and a
. There is a moderate
patient shows the mixed solid
and cystic left ovarian mass
and a moderate amount of
ascites .
t
ne
e.
yn
(Left) Axial NECT obtained
10 days later, when the same
patient presented with acute
pelvic pain, shows a significant
bg
increase in the size of the
mass , which contains
areas of high attenuation
ko
, and an increase in
density of the peritoneal
fluid. (Right) Coronal NECT
oo

interval enlargement of the left
ovarian mass with areas of
high density both within and
eb
outside the mass . Surgery

confirmed hemorrhage and
intraperitoneal rupture of GCT.
://
tp
ht

mass shows a large unilocular
cystic mass filling the
abdomen with a thick rind of
soft tissue density . There
is small amount of ascites
. (Right) Sagittal CECT
the upper part of the mass
and right pleural effusion
. The association of GCT,
pleural effusion, and ascites
constitutes pseudo-Meigs
syndrome. The pleural effusion
resolved after resection of the
tumor.
5
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Ovary
pelvic pain shows a left ovarian
low-attenuation mass with
multiple small cystic spaces,
demonstrating a "Swiss cheese"
pattern. (Right) Coronal CECT
in the same patient shows a left
ovarian mass . Pathology
confirmed GCT.
t
ne
e.
yn
a palpable adnexal mass shows
bg a solid right ovarian tumor
with areas of low attenuation
due to tumor necrosis. (Right)
ko
patient shows a right ovarian

mass with focal areas of
necrosis .
oo
eb
://
tp
ht

old woman with a palpable
abdominal mass shows a
predominantly solid pelvic
mass with areas of low
attenuation due to tumor
necrosis. (Right) Coronal CECT
solid right ovarian mass
with a segmental area of low
attenuation . A torsed ovarian
tumor was found at surgery, and
pathology showed GCT with
segmental infarction.
5
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Obgyne Books Full
Ovary FIBROMA, THECOMA, AND FIBROTHECOMA
Key Facts
Terminology • Dermoid
• Benign ovarian neoplasms classified as sex cord- Pathology
stromal tumor
• Can be part of Gorlin–Goltz syndrome
Imaging o Ovarian fibromas develop in 15–25% of women with
• Solid ovarian mass the syndrome
• Transvaginal ultrasound • 1% associated with Meigs syndrome
o Hypoechoic and attenuating
Clinical Issues
• MR
• Asymptomatic: Usually incidental finding
o T2WI: Low signal intensity
o T1 C+: Negligible enhancement • Adnexal mass
• 1% bilateral • Mean age: 48 years
• Different degrees of enhancement • ~ 4% of all ovarian neoplasms
o Tends to have delayed enhancement • Always benign
• Treatment
Top Differential Diagnoses o Excision of affected ovary by laparoscopy for larger
• Pedunculated uterine leiomyoma lesions
t
• Brenner tumor
ne
e.
yn
ultrasound shows a
hypoechoic ovarian mass
with significant posterior
bg
shadowing masking the
posterior wall. (Right) Coronal
ko
shows a bilobed left ovarian
enhancement that is less than
the degree of enhancement of
oo
the pelvic muscles.

eb
://
tp
ht

a heterogeneous low signal
intensity left ovarian mass
posterior to the uterus
. Note a right ovarian
high signal intensity structure
representing a follicle.
ovarian mass displaying
intensity. The mass has signal
intensity similar to the uterus
.
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FIBROMA, THECOMA, AND FIBROTHECOMA
Ovary
o Limited sound penetration in absence of calcification
TERMINOLOGY
or lack of echogenic interface at start of shadowing
Definitions o ± calcification
• Benign ovarian neoplasm classified as sex cord-stromal o ± cystic change in larger lesions
o Nonattenuating hypo-/hyper-/heterogeneous mass
tumor
o Spectrum including fibroma, thecoma, and atypical
fibrothecoma • Pulsed Doppler
o Wide range of resistive indices depending on
vascularity
IMAGING
• Color Doppler
General Features o Generally hypovascular
• Best diagnostic clue ▪ Occasionally may show increased vascularity
o Solid ovarian mass
▪ Transvaginal ultrasound
– Hypoechoic and attenuating
o TVUS for screening, MR for further characterization
▪ MR
or to differentiate from pedunculated leiomyoma
– T2WI: Low signal intensity
– T1WI C+ FS: Negligible enhancement • Protocol advice
o Highest MHz transducer to see acoustic attenuation
•
t
Location
o 1% bilateral on TVUS
ne
• Size
o Median ~ 13 cm DIFFERENTIAL DIAGNOSIS
•
e.
Morphology
o Well-defined oval, lobulated, round, or bilobed solid Pedunculated Uterine Leiomyoma
mass • Uterine in origin
yn
o Look for bridging vessel sign
▪ ± cystic component in larger lesions
▪ ± calcification • Will often see a separate ovary
• Fibromas and fibrothecomas enhance significantly less
CT Findings
bg than uterine fibroids
• NECT Brenner Tumor
o Nonspecific adnexal mass isodense to uterus
▪ ± calcification • Small tumors
ko
• CECT • When benign, tend to be homogeneous on imaging

o Early: Hypovascular with negligible enhancement studies
o Delayed: Progressive enhancement • Incidental finding when operated for other ovarian
oo
pathology
MR Findings
• T1WI Dermoid
• TVUS: 3 most common imaging features
eb
o Isointense to hypointense compared with uterine

o Cystic lesion with densely echogenic shadowing
myometrium
▪ Mostly homogeneous signal intensity mural nodule
o Signal void foci if calcified o Tip of iceberg sign: Echogenic mass with sound
://
o If thecoma elements predominate attenuation

o Dermoid mesh: Multiple thin echogenic lines and
▪ Fat elements can be identified
tp
▪ Fat identified on frequency selective fat-saturation dots

or out-of-phase gradient echo sequences • MR: Presence of significant amount of macroscopic fat
• is diagnostic
ht
T2WI
o Isointense to hypointense compared with uterine
myometrium PATHOLOGY
▪ Mostly homogeneous signal intensity
o Central high signal intensity cystic areas General Features
o Thin, hypointense capsule may be identified • Associated abnormalities
o Edema may be present in larger lesions o Can be part of Gorlin–Goltz syndrome
• T1WI C+ FS ▪ Rare autosomal dominant syndrome
– Mutation in patched tumor suppressor gene on
o Variable degrees of enhancement
▪ Tends to have delayed enhancement chromosome 9
▪ Characterized by
Ultrasonographic Findings – Multiple basal cell carcinomas of skin
• Grayscale ultrasound – Odontogenic keratocysts of jaw
o Transabdominal and transvaginal US (TVUS) – Intracranial calcification
o Hypoechoic mass – Plantar and palmar pits
▪ With edge shadows – Craniofacial anomalies
▪ With sound attenuation ▪ Ovarian fibromas develop in 15–25% of women
with Gorlin–Goltz syndrome
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– Typically bilateral in 75% of cases; calcified, • May be mistaken for gas-containing bowel on TVUS
multinodular, and multifocal and T2WI
▪ Age of onset is usually after puberty, between 16
and 45 years
o Thecoma may be associated with endometrial SELECTED REFERENCES
thickening if it secretes estrogen 1. Rambocas N et al: Gynecologic implications of Gorlin-Goltz
o Thecoma may be associated with hirsutism and syndrome. Int J Gynaecol Obstet. 123(2):166, 2013
2. Yen P et al: Ovarian fibromas and fibrothecomas:
amenorrhea if it secretes androgen
• 1% associated with Meigs syndrome
sonographic correlation with computed tomography and
magnetic resonance imaging: a 5-year single-institution
o Ascites: 10-15%; usually associated with larger experience. J Ultrasound Med. 32(1):13-8, 2013
tumors 3. Zhang H et al: Value of 3.0 T diffusion-weighted imaging
o Pleural effusion in discriminating thecoma and fibrothecoma from other
o Both disappear with removal of tumor adnexal solid masses. J Ovarian Res. 6(1):58, 2013
Gross Pathologic & Surgical Features imaging algorithm. Radiographics. 32(4):1047-64, 2012
• Chalky white hard surface with whorled appearance on 5. Li X et al: Imaging features and pathologic characteristics
of ovarian thecoma. J Comput Assist Tomogr. 36(1):46-53,
cross section
• Fibromas may be cystic and 10% are calcified 6.
2012
Shinagare AB et al: MRI features of ovarian fibroma and
Microscopic Features fibrothecoma with histopathologic correlation. AJR Am J
t
• Fibromas are composed of whorled fascicles of Roentgenol. 198(3):W296-303, 2012
ne
7. Wang S et al: Prediction of benignity of solid adnexal
cytologically bland spindle cells embedded in
masses. Arch Gynecol Obstet. 285(3):721-6, 2012
collagenous stroma
•
8. Okajima Y et al: Intracellular lipid in ovarian thecomas
Fibrothecomas have sheets and nests of plump spindle
e.
detected by dual-echo chemical shift magnetic resonance
cells with lipid-rich cytoplasm (theca-like cells) in a imaging: report of 2 cases. J Comput Assist Tomogr.
background of bland fibroma-like spindle cells 34(2):223-5, 2010
yn
o May have intermixed lutein cells, which explains 9. Shanbhogue AK et al: Clinical syndromes associated with
hormone secreting properties of these tumors ovarian neoplasms: a comprehensive review. Radiographics.
30(4):903-19, 2010
10. Paladini D et al: Imaging in gynecological disease (5):
bg
CLINICAL ISSUES clinical and ultrasound characteristics in fibroma and
fibrothecoma of the ovary. Ultrasound Obstet Gynecol.
Presentation 34(2):188-95, 2009
ko
11. Tanaka YO et al: MR findings of ovarian tumors with
o Asymptomatic: Usually incidental finding hormonal activity, with emphasis on tumors other than sex
12.
cord-stromal tumors. Eur J Radiol. 62(3):317-27, 2007
Kawano Y et al: Magnetic resonance imaging findings in
oo
o Adnexal mass leiomyoma of the ovary: a case report. Arch Gynecol Obstet.
o Adnexal torsion 273(5):298-300, 2006
o Clinical signs of estrogenic or androgenic activity 13. Jung SE et al: CT and MRI findings of sex cord-stromal tumor
eb
of the ovary. AJR Am J Roentgenol. 185(1):207-15, 2005

Demographics 14. Takeshita T et al: Ovarian fibroma (fibrothecoma) with
• Age extensive cystic degeneration: unusual MR imaging findings
o Fibroma: Mean: 48 years in two cases. Radiat Med. 23(1):70-4, 2005
://
o Thecoma: Postmenopausal 15. Yoshitake T et al: Bilateral ovarian leiomyomas: CT and MRI
• Epidemiology
16.
features. Abdom Imaging. 30(1):117-9, 2005
Chang SD et al: Limited-sequence magnetic resonance
o ~ 4% of all ovarian neoplasms
tp
imaging in the evaluation of the ultrasonographically

o Most common sex cord-stromal tumor indeterminate pelvic mass. Can Assoc Radiol J. 55(2):87-95,
2004
ht

• Always benign
17. Cho SM et al: CT and MRI findings of cystadenofibromas of
the ovary. Eur Radiol. 14(5):798-804, 2004
18. Sala EJ et al: Magnetic resonance imaging of benign adnexal
Treatment
• American College of Obstetricians and Gynecologists
disease. Top Magn Reson Imaging. 14(4):305-27, 2003
(ACOG) recommendations with emphasis on differential diagnosis. Radiographics.
o Excision of affected ovary by laparoscopy for larger 22(6):1305-25, 2002
lesions 20. Schwartz RK et al: Ovarian fibroma: findings by contrast-
enhanced MRI. Abdom Imaging. 22(5):535-7, 1997
21. Troiano RN et al: Fibroma and fibrothecoma of the ovary:
DIAGNOSTIC CHECKLIST MR imaging findings. Radiology. 204(3):795-8, 1997
Consider
• Fibrothecoma if significant attenuation of sound on
TVUS in patient with palpable adnexal mass
• Hypoechoic attenuating mass on TVUS
• Hypointense on T2WI with delayed or no
5 enhancement
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Obgyne Books Full
Ovary
(Left) Axial CECT in an 84-year-
with palpable pelvic mass
shows a right ovarian lesion
showing diffuse homogeneous
enhancement. Fibromas tend to
show little initial enhancement,
with more enhancement on
delayed images. (Right) Sagittal
shows a predominantly very low
signal intensity mass with
streaks of high signal intensity
.
t
ne
e.
yn
patient shows a very low signal
intensity right ovarian mass
bg with small foci of high signal
intensity . (Right) Axial T1WI
a relatively homogeneous low
ko
signal intensity right ovarian mass

.
oo
eb
://
tp
ht

same patient shows a low signal
intensity right ovarian mass .
the same patient shows the right
ovarian mass with minimal
enhancement. Pathological
evaluation revealed a fibroma.
Fibromas tend to show minimal
initial enhancement with
increasing enhancement on more
delayed imaging.
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ultrasound in a 34-year-
old woman with a palpable
adnexal mass shows a
left ovarian mass that
demonstrates solid and a
cystic components. (Right)
shows a left ovarian mass
with a fluid-attenuation cystic
component and a solid
component that is slightly
less enhancing than the uterine
myometrium .
t
ne
e.
yn
a cystic component
bg
and a solid component
demonstrating heterogeneous
high signal intensity. The high
ko
signal intensity is unusual for

fibromas and likely reflects
edema. (Right) Axial T1WI
oo

a left ovarian mass with
a low signal intensity cystic
eb
component demonstrating
://
tp
ht

a low signal intensity cystic
component demonstrating
with a nonenhancing
cystic component and
an intensely enhancing solid
component . Pathological
evaluation revealed a
fibrothecoma.
5
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Ovary
(Left) Axial transabdominal color
Doppler ultrasound in a 42-year-
pelvic pain shows a moderately
vascular solid left ovarian mass
. There is a central area of
increased echogenicity .
patient shows a left ovarian
mass showing homogeneous
attenuation similar to or slightly
less than that of the pelvic
skeletal muscles.
t
ne
e.
yn
heterogeneous mass with
bg signal intensity that is similar
to or slightly higher than that
of the pelvic skeletal muscles.
Small internal foci of high signal
ko
intensity are likely due to

cystic change. (Right) Axial
oo

low signal intensity, slightly less
than that of the pelvic skeletal
eb
muscles.
://
tp
ht

ovarian mass demonstrating
intensity, slightly less than that
of the pelvic skeletal muscles.
(Right) Axial T1 C+ FS MR in the
poor enhancement relative to the
surrounding normal left ovarian
tissue . Pathological evaluation
revealed a fibroma.
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Ovary SERTOLI-STROMAL CELL TUMORS
Key Facts
• Classified as a group of ovarian sex cord-stromal • Granulosa cell tumor
tumors • Fibroma, fibrothecoma, and thecoma
Imaging • Sclerosing stromal tumor of ovary
• Well-defined, enhancing, solid ovarian mass Pathology
• Mostly unilateral • Classification of Sertoli-stromal cell tumors
• Tumor size varies and can reach up to 15 cm o Sertoli-Leydig cell tumors
• Multilocular cystic Sertoli-Leydig cell tumors have o Sertoli cell tumor
been reported o Stromal-Leydig cell tumor
• MR • Most of these tumors have benign clinical courses
o Variable signal intensity depending on amount of
fibrous and fatty components Clinical Issues
• PET/CT • Usually occur in young women
o Multiple reports show increased metabolic activity • Represent < 1% of all ovarian tumors
in Sertoli-stromal cell tumors • Most presenting symptoms are due to virilization
t
ne
e.
yn
palpable adnexal mass shows
bg
a slightly hyperechoic left
ovarian solid mass . (Right)
ko
vascularity of the left ovarian
mass with low-resistance
oo
flow.
eb
://
tp
ht

enhancing solid left ovarian
mass . Small areas of low
attenuation are seen within
the mass. (Right) Sagittal T1
C+ FS MR shows marked
enhancement of the tumor
. Note that the fibrous
components demonstrate
relatively less enhancement.
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SERTOLI-STROMAL CELL TUMORS
Ovary
o Nonenhancing cystic or necrotic components can
TERMINOLOGY
also be seen
Synonyms
• Sertoli-Leydig cell tumor: Androblastoma or • Grayscale ultrasound
arrhenoblastomas
o Heterogeneous echogenicity similar to soft tissue
Definitions o Anechoic or hypoechoic cystic areas may also be seen
• Classified as group of ovarian sex cord-stromal tumors o Tumors containing Leydig cell elements may show
• Include Sertoli-Leydig cell tumors, Sertoli cell tumor, increased echogenicity
and Stromal-Leydig cell tumor • Color Doppler
o Intratumoral vascularity can be detected
o Detection of vascularity in tumor helps in excluding
IMAGING
complex cyst
General Features • Power Doppler
• Best diagnostic clue o Provides improved detection of intratumoral
o Well-defined, enhancing, solid ovarian mass vascularity
o No imaging features to differentiate between
PET/CT
•
different subtypes
Location
• Multiple reports show increased metabolic activity in
t
Sertoli-stromal cell tumors
o Mostly unilateral
• May be helpful in small tumors not detected on US or
ne
o Bilateral tumors are very rare
MR
• Size
o Tumor size varies and can reach up to 15 cm
e.
▪ Stromal-Leydig cell tumors are usually small (1-3
cm) o Transvaginal US or MR can be used to detect these
▪ Sertoli cell tumors are somewhat larger (4-7 cm)
yn
tumors
▪ Sertoli–Leydig cell tumors are variable in size o MR with contrast may be better to detect small
o Hormonally active tumors are usually small at tumors
presentation
bg
• Morphology DIFFERENTIAL DIAGNOSIS
o Mostly nodular solid tumors
o Cystic, necrotic, and hemorrhagic components may Granulosa Cell Tumor
ko
be present • Most commonly present with estrogenic

o Multilocular cystic tumors have been reported with manifestations
• Can have various appearances including solid, mixed
oo
Sertoli-Leydig cell subtypes

cystic and solid, or completely cystic tumors
CT Findings
• NECT Fibroma, Fibrothecoma, and Thecoma
• Typically low signal intensity on T2WI due to their
eb
o Soft tissue attenuation lesion

o Calcification is rare abundant collagen and fibrous contents
• CECT • Intratumoral edema or cellular components may have
o Marked enhancement in solid portion of tumor
://
intermediate to high signal intensity

o Enhancement can be homogeneous or • Fibroma shows no estrogenic activity
heterogeneous • Lipid-rich thecoma can show estrogenic activity
tp
o Nonenhancing cystic or necrotic components can

Sclerosing Stromal Tumor of Ovary
• Masses with cystic and heterogeneous solid
also be seen
ht
MR Findings components
• T1WI o Demonstrate early peripheral enhancement with
o Variable signal intensity depending on amount of centripetal progression
fibrous and fatty components
o Small tumors may not be easily differentiated from
PATHOLOGY
ovarian stroma
• T2WI General Features
o Variable signal intensity depending on amount of • Genetics
fibrous and fatty components o Increased incidence of ovarian sex cord-stromal
o Intermediate signal intensity in solid component tumors in patients with pleuropulmonary blastoma
o Low signal intensity can be seen in fibrous stroma (PPB)
o High signal intensity cystic or necrotic areas can be ▪ PPB is the most common primary lung cancer of
seen childhood
• T1WI C+ – Pulmonary analog of other embryonal
o Marked enhancement in solid portion of tumor neoplasms in this age group such as Wilms
o Enhancement can be homogeneous or tumor, neuroblastoma, retinoblastoma
heterogeneous
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▪ Germline DICER1 mutations are found in patients CLINICAL ISSUES

with PPB-associated ovarian sex cord-stromal
tumors Presentation
– Majority of cases are Sertoli-Leydig cell tumors • Most common signs/symptoms
– Data suggest that Sertoli-Leydig cell tumors o Sertoli-Leydig cell tumor
associated with PPB occur at a younger age than ▪ Most common presenting symptom is virilization
sporadic examples ▪ Loss of female secondary sex characteristics
▪ DICER1 mutations may also be found in other – Oligomenorrhea
ovarian sex cord-stromal tumors – Amenorrhea
▪ DICER1 mutations are associated with both – Atrophy of breasts
familial multinodular goiter and Sertoli-Leydig cell – Disappearance of female body contours
tumors ▪ Progressive masculinization
Staging, Grading, & Classification – Acne
• Sertoli-stromal cell tumors – Increasing facial hair growth
– Temporal balding
o Sertoli-Leydig cell tumors
o Sertoli cell tumor – Deepening of voice
o Stromal-Leydig cell tumor – Enlargement of clitoris
o Sertoli cell tumor
Gross Pathologic & Surgical Features ▪ More commonly estrogenic than androgenic
t
• Yellow-tan, nodular, solid tumors that rarely contain ▪ Patients may develop hypertension because of
ne
cysts renin secretion
• Poorly differentiated tumors have more necrosis or ▪ May be associated with Peutz-Jeghers syndrome (in
hemorrhage 11% of cases)
e.
o Stromal-Leydig cell tumor
Microscopic Features ▪ More commonly androgenic than estrogenic
• Sertoli-stromal cell tumors contain (either in pure form •
yn
or in various combinations) o Increased serum testosterone and androstenedione
o Sertoli cells o Abdominal swelling and pain
o Cells resembling rete epithelial cells o Increased red blood cell count
bg
o Cells resembling fibroblasts
o Leydig cells Demographics
• Sertoli-Leydig cell tumor • Age
ko
o Composed of variable proportions of Sertoli cells, o Sertoli-Leydig cell tumor

Leydig cells, and in the case of intermediate and ▪ Usually occurs in young women
poorly differentiated neoplasms, primitive gonadal – Average age is 25 years
oo
stroma, rete epithelial cells, &/or heterologous – 75% of cases are < 30 years
elements o Sertoli cell tumor
▪ Heterologous elements are various, such as ▪ Typically occurs in young patients
▪ Mean age: 30 years
eb
carcinoid, mesenchymal, and mucinous epithelial

tissues with most common being gastrointestinal o Stromal-Leydig cell tumor
types ▪ Typically occurs in postmenopausal women
o Divided into 4 subtypes ▪ Mean age: 60 years
://
▪ Well differentiated • Epidemiology

▪ Intermediately differentiated o Sertoli-stromal cell tumors are rare
tp
▪ Poorly differentiated ▪ Represent < 1% of all ovarian tumors

▪ Retiform pattern o Sertoli-Leydig cell tumors are the most common
o Immunohistochemical staining is positive for α-
ht
virilizing ovarian tumors

inhibin (sex cord-stromal marker) and positive for
CK7 for mucinous elements Natural History & Prognosis
• Sertoli cell tumor • Most of these tumors have benign clinical courses
o Positive for inhibin in 82% of cases o However, malignancy can be seen in ~ 20% of cases of
o Negative for epithelial membrane antigen and Sertoli-Leydig cell tumors
chromogranin • Prognostic factors include
• Stromal-Leydig cell tumor o Stage
o Degree of differentiation
o Analogous to luteinized thecoma (partly luteinized
o Presence of heterologous elements
theca cell tumor) but differs from the latter by
presence of crystals of Reinke Treatment
o Composed of nodules of Leydig cells within
neoplastic stromal proliferation
• Individualized depending on
o Patient's age and preference
o Tumor grade and stage
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Ovary
• Preservation of fertility is important in young women 9. Herrera JD et al: Hyperandrogenism due to a testosterone-
secreting Sertoli-Leydig cell tumor associated with a
with tumors confined to ovary
o Young women with stage I tumors can be treated dehydroepiandrosterone sulfate-secreting adrenal adenoma
in a postmenopausal woman: case presentation and review
with unilateral salpingo-oophorectomy
• Stage II or higher disease requires total abdominal 10.
of literature. Endocr Pract. 15(2):149-52, 2009
Azuma A et al: A case of Sertoli-Leydig cell tumour of the
hysterectomy and bilateral salpingo-oophorectomy ovary with a multilocular cystic appearance on CT and MR
• Adjuvant therapy may be given with radiation or imaging. Pediatr Radiol. 38(8):898-901, 2008
combination chemotherapy 11. Demidov VN et al: Imaging of gynecological disease
o Used in cases with tumors containing poorly (2): clinical and ultrasound characteristics of Sertoli cell
differentiated elements or heterologous elements tumors, Sertoli-Leydig cell tumors and Leydig cell tumors.
12. Caringella A et al: A case of Sertoli-Leydig cell tumor in a
DIAGNOSTIC CHECKLIST postmenopausal woman. Int J Gynecol Cancer. 16(1):435-8,
2006
Consider 13. Roth LM: Recent advances in the pathology and
• Virilization in a female can be caused by several classification of ovarian sex cord-stromal tumors. Int J
Gynecol Pathol. 25(3):199-215, 2006
different conditions
o Cushing syndrome 14. Elbadrawy M et al: Secondary amenorrhoea due to Leydig
o Adrenal neoplasms cell tumour. J Obstet Gynaecol. 25(5):529-30, 2005
15. Jung SE et al: CT and MRI findings of sex cord-stromal tumor
o Ovarian neoplasms
t
of the ovary. AJR Am J Roentgenol. 185(1):207-15, 2005
o Other ovarian conditions such as
ne
16. Oliva E et al: Sertoli cell tumors of the ovary: a
▪ Polycystic ovary syndrome clinicopathologic and immunohistochemical study of 54
▪ Stromal hyperplasia cases. Am J Surg Pathol. 29(2):143-56, 2005
▪ Stromal hyperthecosis 17. Appetecchia M et al: Sertoli-Leydig cell androgens-estrogens
e.
• Most patients undergo extensive clinical, laboratory secreting tumor of the ovary: ultra-conservative surgery. Eur
J Obstet Gynecol Reprod Biol. 116(1):113-6, 2004
and imaging work-up for definitive diagnosis
• 18. Tanaka YO et al: Functioning ovarian tumors: direct and
yn
Imaging is indicated depending on clinical scenario
•
indirect findings at MR imaging. Radiographics. 24 Suppl
In many cases, appropriate imaging can be a problem- 1:S147-66, 2004
solving tool 19. Jung SE et al: CT and MR imaging of ovarian tumors
• Sertoli-Leydig cell tumors in some patients with
bg with emphasis on differential diagnosis. Radiographics.
virilization may be small and difficult to detect on 22(6):1305-25, 2002
imaging 20. Lantzsch T et al: Sertoli-Leydig cell tumor. Arch Gynecol
o Exploratory laparotomy with intraoperative selective Obstet. 264(4):206-8, 2001
ko
venous blood sampling may be useful be to localize

these small tumors
oo

• Predominantly solid, unilateral ovarian mass in patient
with virilization
eb
SELECTED REFERENCES
1. Abu-Zaid A et al: Poorly differentiated ovarian sertoli-leydig
://
cell tumor in a 16-year-old single woman: a case report and

literature review. Case Rep Obstet Gynecol. 2013:858501,
tp
2013
2. Cai SQ et al: Ovarian Sertoli-Leydig cell tumors: MRI
findings and pathological correlation. J Ovarian Res.
ht
6(1):73, 2013
3. Guo L et al: Sertoli-Leydig cell tumor presenting
hyperestrogenism in a postmenopausal woman: a case
report and review of the literature. Taiwan J Obstet Gynecol.
51(4):620-4, 2012
4. Prassopoulos V et al: Leydig cell tumour of the ovary
localised with positron emission tomography/computed
tomography. Gynecol Endocrinol. 27(10):837-9, 2011
5. Rio Frio T et al: DICER1 mutations in familial multinodular
goiter with and without ovarian Sertoli-Leydig cell tumors.
JAMA. 305(1):68-77, 2011
6. Schultz KA et al: Ovarian sex cord-stromal tumors,
pleuropulmonary blastoma and DICER1 mutations: a report
from the International Pleuropulmonary Blastoma Registry.
Gynecol Oncol. 122(2):246-50, 2011
7. Ozülker T et al: Incidental detection of Sertoli-Leydig cell
tumor by FDG PET/CT imaging in a patient with androgen
insensitivity syndrome. Ann Nucl Med. 24(1):35-9, 2010
8. Shanbhogue AK et al: Clinical syndromes associated with
ovarian neoplasms: a comprehensive review. Radiographics.
30(4):903-19, 2010 5
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increasing facial hair shows a
small (1.8 cm) right ovarian
increased echogenicity. (Right)
Sagittal transvaginal power
blood flow within the ovarian
mass . Pathology confirmed
stromal-Leydig cell tumor.
t
ne
e.
yn
amenorrhea and acne shows
bg
a subtle right ovarian mass
that shows mild increased
echogenicity relative to the
ko
normal ovary (calipers).

oo

increased flow within the right
ovarian mass .
eb
://
tp
ht
(Left) Axial CECT during the

arterial phase in the same
patient shows a markedly
enhancing solid right ovarian
mass . (Right) Axial CECT
during the venous phase in the
same patient shows uniform
enhancement of the right
ovary . The mass noted
during the arterial phase is not
seen on the venous phase.
Pathology confirmed Sertoli-
Leydig tumor.
5
170
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Ovary
with amenorrhea and increased
facial hair shows a right ovarian
mass . The mass displays
predominantly high signal
muscles, with small foci of
even higher signal intensity .
Note the normal right ovary
with multiple small follicles .
(Right) Coronal T2WI MR in the
same patient shows the high
signal intensity right ovarian mass
.
t
ne
e.
yn
same patient shows a subtle right
ovarian mass . The mass is
bg slightly hyperintense relative to
pelvic muscles. (Right) Axial
shows a right ovarian mass .
ko
The mass is slightly hyperintense

relative to pelvic muscles.
oo
eb
://
tp
ht

the same patient shows intense
enhancement of the right ovarian
mass . (Right) Coronal T1WI
shows intense enhancement
of the right ovarian mass .
Surgery confirmed Sertoli-Leydig
tumor.
5
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Ovary SCLEROSING STROMAL TUMOR
Key Facts
• Classified as benign sex cord-stromal tumor • Ovarian fibroma
Imaging • Ovarian carcinoma
• Unilateral • Krukenberg tumor
• Variable size, usually 3-5 cm • Metastases to ovary
• Solid mass with pseudolobular pattern • Massive ovarian edema
• CECT and dynamic T1 C+ FS Clinical Issues
o Early avid peripheral enhancement with centripetal • Common presenting clinical symptoms are pelvic
progression pain, hypermenorrhea, and menstrual irregularities
o Lack of enhancement of central area, even on • Anovulation due to hormonal secretion (estrogen,
delayed images progesterone, testosterone)
• Ultrasound • Predominantly during 2nd and 3rd decades of life
o Heterogeneous solid mass with posterior shadowing • ~ 6% of ovarian stromal tumors
o May have hypoechoic central stellate area • Surgical removal of tumor is curative
o Increased peripheral vascularity
• No local or distant recurrence
t
ne
e.
yn
ultrasound shows a
with small cleft-like
bg
cystic spaces . (Right)
Sagittal T2WI MR shows a
heterogeneous signal intensity
ko
mass. The solid part of the
mass has heterogeneous
high signal intensity
with scattered areas of low
oo
signal intensity that are

distributed predominantly in
the peripheral portion of the
eb
mass.
://
tp
ht
(Left) Axial T1 C+ FS MR
shows the typical avid
enhancement of the outer
part of the mass with
a pseudolobular pattern.
Pathology revealed sclerosing
stromal tumor. (Courtesy T.
Cunha, MD.) (Right) Gross
pathology shows a pale and
fleshy cut surface with white
and yellow areas. Central
cystic spaces are also seen.
(Courtesy S. Kim, MD.)
5
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SCLEROSING STROMAL TUMOR
Ovary
TERMINOLOGY – Lack of enhancement of central area, even
on delayed images, representing collagenous
Abbreviations acellular areas
• Sclerosing stromal tumor (SST) Ultrasonographic Findings
Definitions • Grayscale ultrasound
• Classified as benign sex cord-stromal tumor o Solid mass of heterogeneous echogenicity and
posterior shadowing
o Irregular thick septae and tumor wall
IMAGING o Solid mass with hypoechoic central stellate area
o Small amount of ascites
General Features
• Best diagnostic clue • Pulsed Doppler
o Low-resistance flow
o Early and strong enhancement of peripheral tumor
tissue with centripetal progression on dynamic • Color Doppler
o Increased peripheral vascularity
contrast-enhanced MR and CT
o No arteriovenous shunting
• Location
o Usually unilateral Imaging Recommendations
• Size • Best imaging tool
o Variable, usually 3-5 cm o MR
t
• •
ne
Morphology Protocol advice
o Solid or complex cystic with mural nodularity o T2WI and dynamic contrast-enhanced T1WI with fat
CT Findings saturation
e.
• NECT
o Solid mass of heterogeneous attenuation DIFFERENTIAL DIAGNOSIS
o Nodular periphery and low attenuation irregular
yn
central area Ovarian Fibroma
• CECT • Fibromas and thecomas are uncommon in first 3
o Early and strong enhancement of periphery decades of life
bg
o Centripetal progression of enhancement on delayed • Usually uniform low signal intensity on T2WI
images • Mild and low enhancement on dynamic contrast-
enhanced MR
ko
MR Findings
• T1WI Ovarian Carcinoma
o Thin outer rim with low signal intensity • Older age group
• High values of tumor markers such as CA125 &/or
oo
o Intermediate signal intensity in outer part of lesion

o Low signal intensity in central area CA19-9
• T2WI • Signal intensity of solid components in ovarian cancer
eb
o Solid mass with hyperintense cystic components or on T2WI are lower than those of SST
heterogeneous solid mass of intermediate to high • Ovarian carcinoma shows early enhancement and fast
wash-out on dynamic contrast-enhanced MR
• Ascites very common
signal intensity
▪ Cases of solid hypointense masses have been
://
described Krukenberg Tumor

o Rim of peripheral low signal intensity
• Presence of primary gastrointestinal malignancy at
tp
▪ Compressed ovarian cortex due to a slow-growing time of diagnosis

tumor
o Pseudolobular or spoke-wheel pattern of outer part of • Usually bilateral
ht
lesion
• Usually solid
▪ Intermediate to low signal intensity nodules Metastases to Ovary
interposed between high signal intensity septa
o Very high signal intensity in central area
• Presence of primary tumor, such as breast or
endometrium
• T1WI C+ FS • Usually bilateral
o Striking contrast enhancement with internal small • Cystic or solid
cleft and cysts
o Dynamic T1 C+ FS Massive Ovarian Edema
▪ Early peripheral enhancement with centripetal • Preserved ovarian follicles within edematous stroma
progression • Absence of lesion heterogeneity
– Early avid enhancement of outer part of mass
with typical pseudolobular pattern representing
pseudolobulated cellular areas
PATHOLOGY
– Later enhancement of intermediate part of General Features
mass with centripetal progression representing
edematous ovarian stroma
• Etiology
o Arise from perifollicular myoid stromal cells in theca
externa 5
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Ovary SCLEROSING STROMAL TUMOR
• Associated abnormalities SELECTED REFERENCES

o Endometrial hyperplasia (rare)
1. Park SM et al: A sclerosing stromal tumor of the ovary with
Gross Pathologic & Surgical Features masculinization in a premenarchal girl. Korean J Pediatr.
• Unilateral, firm, solid, lobulated tumor 54(5):224-7, 2011
• 3-5 cm diameter 2. Chang YW et al: Bilateral sclerosing stromal tumor of the
• Cut surface is pale and fleshy with white and yellow

ovary in a premenarchal girl. Pediatr Radiol. 39(7):731-4,
2009
areas 3. Wada H et al: Sclerosing stromal tumor of the ovary with
• Cystic spaces may be seen occasionally atypical magnetic resonance imaging findings in a middle-
• Rarely presents as a unilocular cyst 4.
aged woman. Jpn J Radiol. 27(6):247-51, 2009
Jung SE et al: CT and MRI findings of sex cord-stromal tumor
Microscopic Features of the ovary. AJR Am J Roentgenol. 185(1):207-15, 2005
• Pseudolobulated cellular zones alternate with acellular 5. Calabrese M et al: Sclerosing stromal tumor of the ovary
in pregnancy: clinical, ultrasonography, and magnetic
edematous or dense collagenous connective tissue
resonance imaging findings. Acta Radiol. 45(2):189-92, 2004
zones
•
6. Deval B et al: Sclerosing stromal tumor of the ovary: color
Cellular areas contain numerous branched vessels Doppler findings. Ultrasound Obstet Gynecol. 22(5):531-4,
• Tumor cells rounded with vacuolated or eosinophilic 2003
cytoplasm; spindle cells are admixed 7. Fefferman NR et al: Sclerosing stromal tumor of the ovary in
• Prominent sclerosis around individual cells and cell a premenarchal female. Pediatr Radiol. 33(1):56-8, 2003
t
clusters 8. Kim JY et al: Sclerosing stromal tumor of the ovary: MR-
•
ne
pathologic correlation in three cases. Korean J Radiol.
Immunohistochemical stains are positive for desmin
4(3):194-9, 2003
and smooth muscle actin in spindle cells only 9. Kuscu E et al: Sclerosing stromal tumor of the ovary: a case
e.
CLINICAL ISSUES 10. Mikami M et al: Magnetic resonance imaging in sclerosing
stromal tumor of the ovary. Int J Gynaecol Obstet.
Presentation 83(3):319-21, 2003
yn
• Most common signs/symptoms 11. Yerli H et al: Sclerosing stromal tumor of the ovary with
torsion. MRI features. Acta Radiol. 44(6):612-5, 2003
o Common presenting clinical symptoms are pelvic 12. Torricelli P et al: Sclerosing stromal tumor of the ovary: US,
pain, hypermenorrhea, and menstrual irregularities
bg CT, and MRI findings. Abdom Imaging. 27(5):588-91, 2002
• Other signs/symptoms 13. Joja I et al: Sclerosing stromal tumor of the ovary: US,
o Anovulation due to hormonal secretion (estrogen, MR, and dynamic MR findings. J Comput Assist Tomogr.
progesterone, testosterone) 25(2):201-6, 2001
ko
o Palpable mass 14. Ihara N et al: Sclerosing stromal tumor of the ovary: MRI. J
Comput Assist Tomogr. 23(4):555-7, 1999
o Masculinization
15. Matsubayashi R et al: Sclerosing stromal tumor of the ovary:
o Abnormal uterine bleeding
oo
radiologic findings. Eur Radiol. 9(7):1335-8, 1999

o Ascites 16. Duska LR et al: Masculinizing sclerosing stromal cell tumor
in pregnancy: report of a case and review of the literature.
Demographics
• Age
Eur J Gynaecol Oncol. 19(5):441-3, 1998
eb
17. Kim SH et al: CT and MR findings of Krukenberg tumors:

o Predominantly during 2nd and 3rd decades of life, comparison with primary ovarian tumors. J Comput Assist
with a mean age of 28 years Tomogr. 20(3):393-8, 1996
• 18. Ha HK et al: Krukenberg's tumor of the ovary: MR imaging
://
Epidemiology
o SST accounts for 6% of ovarian stromal tumors features. AJR Am J Roentgenol. 164(6):1435-9, 1995
19. Hamper UM et al: Transvaginal color Doppler sonography
tp
Natural History & Prognosis of adnexal masses: differences in blood flow impedance
• Surgical removal of tumor is curative in benign and malignant lesions. AJR Am J Roentgenol.
• No local or distant recurrence

160(6):1225-8, 1993
ht
20. Shaw JA et al: Sclerosing stromal tumor of the ovary:

an ultrastructural and immunohistochemical analysis
Treatment
• Oophorectomy
with histogenetic considerations. Ultrastruct Pathol.
16(3):363-77, 1992
21. Kawamura N et al: Sclerosing stromal tumour of the ovary.
Br J Radiol. 60(718):1031-3, 1987
DIAGNOSTIC CHECKLIST 22. Hsu C et al: Sclerosing stromal tumor of the ovary: case
report and review of the literature. Int J Gynecol Pathol.
Consider
• SST in young female patient presenting with prolonged
2(2):192-200, 1983
23. Ho Yuen B et al: Sclerosing stromal tumor of the ovary.
menstrual irregularity and adnexal mass Obstet Gynecol. 60(2):252-6, 1982
24. Chalvardjian A et al: Sclerosing stromal tumors of the ovary.
• Dynamic contrast-enhanced MR findings typical for
Cancer. 31(3):664-70, 1973
SST
o Early striking peripheral enhancement with
centripetal progression
o Lack of enhancement of central area, even on delayed
images
5
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SCLEROSING STROMAL TUMOR
Ovary
with palpable pelvic mass shows
a left ovarian heterogeneous
mass demonstrating high
signal intensity. Note the
multifibroid uterus , normal
right ovary , and small amount
of free pelvic fluid . (Right)
Coronal T2WI MR in the same
patient shows a heterogeneous
hyperintense left ovarian mass
resting on the top of the
urinary bladder.
t
ne
e.
yn
patient shows a left ovarian mass
bg low signal intensity relative to
pelvic skeletal muscles. (Right)
patient shows a homogeneous
ko
low signal intensity left ovarian

mass .
oo
eb
://
tp
ht

left ovarian mass with areas
of nonenhancement likely
due to necrosis. The degree of
enhancement is higher than
in the normal myometrium
and uterine fibroids . (Right)
same patient shows the intensely
enhancing left ovarian mass
superior to the multifibroid uterus
revealed sclerosing stromal
tumor.
5
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Ovary OVARIAN METASTASES
Key Facts
Terminology o T1WI: Solid components demonstrate intermediate
• Secondary (metastatic) neoplasms to ovary signal intensity
o T2WI: Solid components demonstrate
• Krukenberg tumor: Subtype of metastatic tumors that heterogeneous signal intensity
contain > 10% mucin-filled signet cells in cellular o T1WI C+: Solid components show marked
stroma
Imaging • US
• Bilateral ovarian masses in patients with known o Heterogeneous echotexture
o Solid components demonstrate vascularity on
primary carcinoma
• Metastases to ovary are usually solid masses Doppler evaluation
• Often large • PET/CT is modality of choice for tumor staging
• Lobulated masses with smooth external contour and shows increased metabolic uptake in ovarian
• CECT metastases
o Solid components often demonstrate Top Differential Diagnoses
inhomogeneous enhancement
o Cystic and necrotic areas do not enhance
• Primary ovarian cancer
• • Ovarian lymphoma
t
MR
ne
e.
yn
a 57-year-old woman with a
history of rectal carcinoma
bg
shows a right ovarian mixed
solid and cystic mass with
blood flow within the solid
ko
component. (Right) Axial
CECT in a 42-year-old woman
with a history of colon cancer
shows bilateral ovarian masses
oo
, larger on the left side. The

masses show mixed solid and
cystic components.
eb
://
tp
ht

with palpable abdominal
masses shows bilateral solid
ovarian masses and
an appendiceal mass .
ovarian masses and an
appendiceal mass . The
size of the appendiceal mass
is much smaller than the
ovarian masses. Surgery
confirmed ovarian metastases
from a primary appendiceal
adenocarcinoma.
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OVARIAN METASTASES
Ovary
o Solid components show marked heterogeneous
TERMINOLOGY
enhancement
Definitions
• Secondary (metastatic) neoplasms to ovary • Grayscale ultrasound
• Krukenberg tumor o Ovarian mass with heterogeneous echotexture
o Subtype of metastatic tumors that contain > 10%
mucin-filled signet cells in cellular stroma
• Color Doppler
o Solid components demonstrate vascularity
o Usually from gastrointestinal tract, with 76% arising
from stomach Nuclear Medicine Findings
o The term Krukenberg tumor is sometimes used • PET
inappropriately by some to include all metastatic o PET/CT is modality of choice for tumor staging
ovarian carcinomas and shows increased metabolic uptake in ovarian
• High-stage mucinous tumors involving ovary metastases
frequently represent metastases from extraovarian
primary sites and are often misdiagnosed as primary Imaging Recommendations
ovarian mucinous tumors • Best imaging tool
o Ultrasound is usually 1st modality to demonstrate
ovarian involvement in patient with known
IMAGING malignancy
t
o CT and MR can be used to assess extent of disease
ne
General Features
o Bilateral ovarian masses in patients with known DIFFERENTIAL DIAGNOSIS
e.
primary carcinoma
o Metastases to ovary are usually solid masses Primary Ovarian Cancer
▪ However, cystic and necrotic areas can be seen and • Most primary ovarian carcinomas are predominantly
yn
tumors may resemble primary ovarian cancer cystic masses
• Location o Multilocularity of cystic mass suggests primary
o Usually bilateral ovarian tumor
•
o Majority of metastases from colon are bilateral (80%)
bgMost secondary malignancies of ovary are
▪ If unilateral, more common in right ovary predominantly solid or mixture of solid and cystic areas
• Size Ovarian Lymphoma
ko
o Often large masses
• Ovarian lymphomas are often homogeneous solid
• Morphology masses
o Lobulated masses with smooth external contour • Extensive involvement of lymph node chains is seen in
oo
▪ 92% of ovarian metastases from colon cancer show lymphoma

smooth margin compared with 45% of primary
ovarian cancers
PATHOLOGY
eb
CT Findings
• NECT General Features
o Metastatic ovarian tumors often have soft tissue • Etiology
://
o Metastases to ovary occur by hematogenous,

density but may demonstrate low-attenuation cystic
or necrotic areas lymphatic, transperitoneal, or direct extension
o Primary sites of nongynecologic tumors
•
tp
CECT
o Solid components often demonstrate ▪ Colon (30%)
– Metastatic colon cancers to ovary usually
inhomogeneous enhancement
ht
o Cystic and necrotic areas do not enhance arise from distal lesions, most commonly
o Metastatic colorectal carcinoma may appear rectosigmoid, followed in decreasing order by
as multilocular cystic lesion with stained-glass transverse colon, ascending colon, cecum, and
appearance descending colon
▪ Loculi with variable attenuation ▪ Stomach (16%), appendix (13%), breast (13%),
pancreas (12%), biliary tract (15%), and liver (4%)
MR Findings o Common gynecologic primary sites
• T1WI ▪ Uterine body (23%), uterine cervix (4%)
o Solid components demonstrate intermediate signal
•
intensity
T2WI • Staging is based on staging system of primary
malignancy
o Solid components demonstrate heterogeneous signal
intensity Gross Pathologic & Surgical Features
o Cystic and necrotic components demonstrate high • Cut surfaces of ovaries may be solid, solid-cystic, or
signal intensity multicystic
o Loculi within multilocular tumors may show variable • Have tendency to preserve contour of ovary
signal intensities • Hemorrhage or necrosis may be present within mass
• T1WI C+ 5
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Microscopic Features • In patients with metastases to ovaries, primary tumor

• Hyperplasia of ovarian stromal cells with significant is often clinically overt and associated with findings of
widespread metastatic disease
number of signet ring cells
• Features favoring metastatic rather than primary • Investigation of gastrointestinal tract is recommended
ovarian neoplasm include in patient without known primary cancer
o Bilaterality
o Nodular pattern of ovarian involvement
o Infiltrative pattern of stromal invasion • Features that are more often seen in metastases to
ovary include
o Microscopic surface deposits of tumor o Bilateral ovarian masses
o Marked lymphovascular invasion (especially in hilum o Predominantly solid appearance of mass
and outside ovary)
o Signet ring cells
o Cells floating in mucin SELECTED REFERENCES
o Variation in growth pattern from 1 nodule to another 1. Alvarado-Cabrero I et al: Metastatic ovarian tumors: a
clinicopathologic study of 150 cases. Anal Quant Cytol
Histol. 35(5):241-8, 2013
CLINICAL ISSUES 2. Guerriero S et al: Preoperative diagnosis of metastatic
ovarian cancer is related to origin of primary tumor.
Presentation
t
3. Ho L et al: Bilateral ovarian metastases from gastric
o Abdominal pain
ne
carcinoma on FDG PET/CT. Clin Nucl Med. 37(5):524-7,
o Palpable pelvic masses 2012
• Other signs/symptoms 4. Willmott F et al: Radiological manifestations of metastasis to
o Occasionally associated hormonal activity can be the ovary. J Clin Pathol. 65(7):585-90, 2012
e.
5. Soslow RA: Mucinous ovarian carcinoma: slippery business.
seen due to reactive ovarian stromal hyperplasia
•
Cancer. 117(3):451-3, 2011
Clinical profile
yn
6. Zaino RJ et al: Advanced stage mucinous adenocarcinoma
o In many cases, there is known history of primary of the ovary is both rare and highly lethal: a Gynecologic
neoplasm Oncology Group study. Cancer. 117(3):554-62, 2011
o Usually symptoms of primary disease precede 7. Abe Y et al: A case of metastatic malignant melanoma of the
bg ovary with a multilocular cystic appearance on MR imaging.
symptoms secondary to ovarian metastasis
o On occasion, presentation is with symptoms related Jpn J Radiol. 27(10):458-61, 2009
8. de Waal YR et al: Secondary ovarian malignancies:
to ovarian mass in patient with no known history of
frequency, origin, and characteristics. Int J Gynecol Cancer.
ko
malignancy 19(7):1160-5, 2009

Demographics 9. Koyama T et al: Secondary ovarian tumors: spectrum of
• Age CT and MR features with pathologic correlation. Abdom

oo
Imaging. 32(6):784-95, 2007

o More common in premenopausal women due to 10. Testa AC et al: Imaging in gynecological disease (1):
vascularity of ovaries ultrasound features of metastases in the ovaries differ
• Epidemiology depending on the origin of the primary tumor. Ultrasound
eb
o 5-15% of malignant ovarian tumors are metastatic Obstet Gynecol. 29(5):505-11, 2007
11. Chang WC et al: CT and MRI of adnexal masses in
tumors to ovary
o 5-30% of cancer patients have ovarian metastases at patients with primary nonovarian malignancy. AJR Am J
://
Roentgenol. 186(4):1039-45, 2006

autopsy 12. Khunamornpong S et al: Primary and metastatic mucinous
o Only 30-40% of ovarian metastases are true adenocarcinomas of the ovary: Evaluation of the diagnostic
tp
Krukenberg tumors approach using tumor size and laterality. Gynecol Oncol.
101(1):152-7, 2006
Natural History & Prognosis 13. Kiyokawa T et al: Krukenberg tumors of the ovary: a
• Poor prognosis with mortality rate of ~ 90% 1 year after
ht
clinicopathologic analysis of 120 cases with emphasis on

ovarian metastasis is discovered their variable pathologic manifestations. Am J Surg Pathol.
30(3):277-99, 2006
Treatment 14. Alcazar JL et al: Transvaginal gray scale and color Doppler
• Radical tumor-reductive surgery sonography in primary ovarian cancer and metastatic
• Often have poor response to chemotherapy tumors to the ovary. J Ultrasound Med. 22(3):243-7, 2003
• Due to high risk of ovarian metastasis, palliative 15. Jung SE et al: CT and MR imaging of ovarian tumors
bilateral oophorectomy may be performed during
22(6):1305-25, 2002
surgery for colon cancer 16. Brown DL et al: Primary versus secondary ovarian
malignancy: imaging findings of adnexal masses in the
Radiology Diagnostic Oncology Group Study. Radiology.
Consider 17. Hann LE et al: Adnexal masses in women with breast cancer:
• Imaging findings of primary ovarian cancer and

US findings with clinical and histopathologic correlation.
Radiology. 216(1):242-7, 2000
metastases to ovaries overlap in many cases, and
confident imaging distinction between the two may be
challenging
5
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OVARIAN METASTASES
Ovary
woman with a history of rectal
cancer shows a heterogeneous
ovarian mixed solid and cystic
mass with an enhancing solid
component and multiple internal
septa . Ovarian metastases
from colonic primaries are
more common with distal
(rectosigmoid) tumors.
t
ne
e.
yn
old woman with a history of
malignant melanoma shows a
bg multilocular cystic right ovarian
mass with thick internal
septations . Bilateral metallic
linear structures represent
ko
Essure contraceptive devices

within the fallopian tubes. (Right)
oo
patient shows the multilocular

cystic mass with internal
septations . Pathological
examination revealed a cystic
eb
tumor containing chocolate-

colored fluid. Histopathology
revealed malignant melanoma.
://
tp
ht

woman with a history of colon
cancer shows a predominantly
solid left ovarian mass
demonstrating heterogeneous
enhancement. (Right) Coronal
the solid left ovarian mass .
Although the tumor is located in
the midline, the presence of the
left ovarian vessels along the
left side of the mass confirms its
left ovarian origin.
5
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old woman with a history of
pancreatic neuroendocrine
tumor secreting vasoactive
intestinal peptide (VIPoma)
shows bilateral ovarian masses.
The right ovarian mass is
predominantly solid, whereas
the left ovarian mass is
mixed solid and cystic. (Right)
patient shows that the left
ovarian mass contains an
and septated larger cystic
component .
t
ne
e.
yn
(Left) Axial fused CT-octreotide
scan shows increased uptake
within the bilateral ovarian
masses . (Right) Coronal
bg
fused CT-octreotide scan
shows increased uptake
within the solid components
ko
of bilateral ovarian masses

. Octreotide scans can
be helpful for evaluation of
oo
tumors that have somatostatin

receptors, such as carcinoids
and neuroendocrine tumors.
eb
://
tp
ht

of colonic carcinoma shows
bilateral multilocular cystic
ovarian masses . The
solid enhancing structure
represents an enlarged
uterus due to leiomyomatosis.
masses and enlarged
leiomyomatous uterus . Also
note the presence of stent
within the sigmoid colon.
5
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OVARIAN METASTASES
Ovary
with a palpable pelvic mass
and had no previous cancer
history shows a predominantly
cystic right ovarian mass ,
demonstrating thick enhancing
septa. (Right) Coronal CECT
predominantly cystic right
ovarian mass with irregular
enhancing septa. Also noted
was a circumferential cecal mass
. Surgery confirmed cecal
mucinous adenocarcinoma
metastasizing to the right ovary.
t
ne
e.
yn
presented with abnormal vaginal
bg bleeding and was found to
have endometrial carcinoma
on biopsy shows endometrial
thickening with myometrial
ko
invasion almost reaching to

the serosal surface. (Right) Axial
oo
shows a right ovarian rounded

lesion of high signal intensity.
Note also the endometrial mass
.
eb
://
tp
ht

same patient shows a subtle right
ovarian mass . (Right) Axial
patient shows enhancement of
the right ovarian mass . The
patient underwent hysterectomy
with bilateral salpingo-
oophorectomy, which confirmed
the presence of metastatic
endometrial carcinoma to the
right ovary. Ovarian metastases
occur in ~ 11% of patients with
endometrial carcinoma and
are more likely in patients with
myometrial invasion.
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Ovary OVARIAN LYMPHOMA
Key Facts
• Ovarian involvement by lymphoma • International Prognostic Index (IPI) was developed
• Most often ovaries are secondarily involved in setting as a more accurate prognostic indicator for ovarian
of systemic lymphoma lymphoma

• No specific imaging finding is pathognomonic • Nonspecific presentation mimicking that of other
• Should be considered when a solid homogeneous ovarian tumors
ovarian mass or bilateral ovarian involvement is seen • Most frequent symptom is a abdominopelvic mass ±
in absence of ascites pain
• Normal ovarian morphology is preserved and there is • Diffuse large B-cell lymphoma is most often seen
no invasion of surrounding structures between 35 and 45 years of age
• FDG PET shows marked uptake in lymphoma • Primary ovarian lymphoma represents only 0.5% of
all non-Hodgkin lymphomas and 1.5% of all ovarian
Top Differential Diagnoses tumors
• Ovarian carcinomas • Most patients with ovarian lymphomas are treated
• Ovarian metastasis with surgery and chemotherapy; radiotherapy is
t
• Solid ovarian neoplasms optional
ne
e.
yn
color Doppler pelvic
ultrasound in an 18-year-
old woman shows an
bg
enlarged hypovascular
right ovary . The ovary
shows homogeneous low
ko
echogenicity without visible
follicles. (Right) Coronal CECT
In a 25-year-old woman shows
bilateral predominantly solid
oo
ovarian masses . Note the

peripheral arrangement of
ovarian follicles in the right
eb
ovarian mass and areas of

necrosis in the left ovarian
mass. Surgery confirmed
bilateral Burkitt lymphoma.
://
tp
ht
(Left) Coronal T2WI FS

MR in a 12-year-old girl
to the pelvic musculature.
(Right) Axial PET/CT in a
increased metabolic activity in
a right ovarian mass . PET/
CT is the modality of choice
for detection of extraovarian
lymphoma.
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OVARIAN LYMPHOMA
Ovary
TERMINOLOGY Nuclear Medicine Findings
Definitions
• PET
o FDG PET shows marked uptake in lymphoma
• Ovarian involvement by lymphoma o Lymphomatous lesions show variable degrees
• Most often ovaries are secondarily involved in setting of of ↑ FDG uptake due to multiple factors, such as
systemic lymphoma histological subtype, grade, and viability of tumor
• Primary ovarian lymphoma is extremely rare Imaging Recommendations
IMAGING o FDG PET is method of choice for staging and
assessment of therapeutic response in lymphoma
General Features
o No specific imaging finding is pathognomonic for a DIFFERENTIAL DIAGNOSIS
diagnosis of ovarian lymphoma
o Should be considered when a solid homogeneous Ovarian Carcinomas
ovarian mass or bilateral ovarian involvement is seen • Have complex structures with cystic or necrotic areas
and solid components
• Unlike lymphoma, ascites is usually present
in absence of ascites
o Normal ovarian morphology is preserved and there is
t
no invasion of surrounding structures Ovarian Metastasis
•
ne
Location
o Ovarian involvement may be bilateral or unilateral
• May resemble lymphoma because both cause diffuse
ovarian enlargement without ascites
o Involvement of small bowel is a common associated
• With ovarian metastasis, primary tumor is usually
e.
finding in Burkitt lymphoma evident on imaging or clinical history
• Size • Extensive involvement of lymph node chains is more
o Variable, but may present as large ovarian masses
yn
common with and suggestive of lymphoma
• Morphology
Solid Ovarian Neoplasms
o Ovaries usually diffusely involved with grossly
preserved morphology; areas of necrosis and cysts • Solid primary tumors may appear similar to lymphoma:
bg Fibroma, fibrothecoma, Sertoli-Leydig cell tumor,
may be found in large tumors
sarcoma, dysgerminoma, granulosa cell tumor, etc.
CT Findings
• CECT
ko
o Well-defined, homogeneous, low-attenuation masses

PATHOLOGY
o Mild to moderate homogeneous enhancement Staging, Grading, & Classification
o Cystic areas and necrosis are rare
• Staging for ovarian lymphomas is controversial
oo
MR Findings • Both Ann Arbor staging system for Hodgkin disease

• T1WI and International Federation of Obstetricians and
eb
o Solid, well-defined mass exhibiting homogeneous Gynecologists (FIGO) staging system for epithelial
tumors have been used to stage ovarian lymphoma
low signal intensity o Limitations of Ann Arbor staging system
• T2WI
▪ Designed for Hodgkin disease, so it is a less accurate
://
o Enlarged ovary with intermediate to high signal

prognostic indicator for non-Hodgkin lymphoma
o Ovaries may be devoid of follicles or follicles may be
o Limitations of FIGO system
tp
displaced at periphery of lesion ▪ Biology of lymphoma and ovarian epithelial

o Septae are occasionally present within ovarian mass
tumors is different
and exhibit hypointense signal due to presence of ▪ FIGO is less sensitive as a prognostic indicator
ht
fibrous tissue
because it does not differentiate between unilateral
o Signal intensity of ovarian lymphoma on T2WI MR
and bilateral disease involvement, which is an
lower than that of most ovarian carcinomas
•
important prognostic factor
T1WI C+
o Both ovarian mass and septae within show • International Prognostic Index (IPI) was developed
as a more accurate prognostic indicator for ovarian
significant contrast enhancement lymphoma
o Enhancement may be peripheral o This index considers
o Cystic areas and necrosis are rare
▪ Patient's age
Ultrasonographic Findings ▪ Performance status
▪ Disease stage (using Ann Arbor system)
• Grayscale ultrasound ▪ Involved extranodal sites
o Well-defined, solid, homogeneous, and hypoechoic
adnexal lesion Gross Pathologic & Surgical Features
o Ovarian follicles may be seen as small anechoic cysts
at periphery of lesion
• Firm, rubbery, or soft mass which may contain areas of
necrosis and cysts when tumor is large
• Color Doppler • Calcifications may be detected after treatment
o Moderate or high vascularity
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Microscopic Features o Tumor size

• Either diffuse or nodular involvement o Stage at presentation
o Histological type
• Lymphomatous cells may be aggregated into islands or ▪ B-cell diseases, particularly follicular lymphoma,
form thin rows of cells within ovary
• Most common histologic types involved in primary have a better prognosis
o Onset of symptoms
ovarian non-Hodgkin lymphoma are Burkitt
lymphoma and diffuse large B-cell lymphoma ▪ Patients presenting with acute onset symptoms
have a poorer prognosis
Criteria for Diagnosis of Primary Ovarian
Treatment
Lymphoma
• Disease is confined to ovary at initial presentation • Most patients with ovarian lymphomas are treated with
surgery and chemotherapy; radiotherapy is optional
o Involvement of regional nodes draining ovary should
not preclude diagnosis of primary ovarian lymphoma
• As it is not possible to predict which patients will
develop generalized disease, it is recommended that
• No abnormal cells are found in peripheral blood or all patients be staged and treated with combination
bone marrow surgery/chemotherapy regimens appropriate for their
• If any extraovarian lymphomatous lesions develop, specific histologies
they occur several months after initial detection of
ovarian lymphoma
t
ne
CLINICAL ISSUES Image Interpretation Pearls
Presentation • Imaging findings of ovarian lymphoma are
nonspecific, but features that suggest lymphoma
e.
include
o Nonspecific presentation mimicking presentation of o Well-defined, homogeneous masses without
other ovarian tumors significant necrosis, hemorrhage, or calcifications
yn
o Most frequent symptom is an abdominopelvic mass o Bilateral ovarian involvement is frequent
± pain
o Acute abdomen, nausea, and vomiting
• Burkitt lymphoma should be considered when there is
bilateral or unilateral ovarian enlargement associated
o Palpable lymphadenopathy
bg
with thickening of small bowel wall
o Vaginal bleeding
o B symptoms such as fever, night sweat, and weight
SELECTED REFERENCES
ko
loss
o Often asymptomatic, discovered incidentally during 1. Miyazaki N et al: Burkitt lymphoma of the ovary: a case
gynecological or radiological examination report and literature review. J Obstet Gynaecol Res.
•
oo

o Ascites may be present but it is rare 2. Crawshaw J et al: Primary non-Hodgkin's lymphoma of the
ovaries: imaging findings. Br J Radiol. 80(956):e155-8, 2007
Demographics 3. Komoto D et al: A case of non-hodgkin's lymphoma of the
• Age
eb
ovary: usefulness of 18F-FDG PET for staging and assessment

of the therapeutic response. Ann Nucl Med. 20(2):157-60,
o Diffuse large B-cell lymphoma is most often seen
2006
between 35 and 45 years of age 4. Lanjewar DN et al: HIV-associated primary non-Hodgkin's
://
o Diffuse small cell lymphoma is more frequently seen lymphoma of ovary: A case report. Gynecol Oncol. 2006
in children and adolescents 5. Koksal Y et al: A case of primary ovarian lymphoma in
o Follicular lymphoma is seen in patients older than 30 a child with high levels of CA125 and CA19-9. J Pediatr
tp
years Hematol Oncol. 27(11):594-5, 2005

• Epidemiology 6. Niitsu N et al: Ovarian follicular lymphoma: a case report
ht
and review of the literature. Ann Hematol. 81(11):654-8,

o Ovary is most common site in female genital tract to
2002
be involved with lymphoma 7. Ferrozzi F et al: Non-Hodgkin lymphomas of the ovaries: MR
o Secondary ovarian lymphoma is more frequent and findings. J Comput Assist Tomogr. 24(3):416-20, 2000
can occur as a part of disseminated lymphoma or as 8. Mansouri H et al: Primary malignant lymphoma of the
initial presentation of occult nodal disease ovary: an unusual presentation of a rare disease. Eur J
▪ Malignant lymphomas involve ovaries at necropsy Gynaecol Oncol. 21(6):616-8, 2000
or autopsy in 7–26% of patients with lymphoma 9. Mitsumori A et al: MR appearance of non-Hodgkin's
o Primary ovarian lymphoma represents only 0.5% of lymphoma of the ovary. AJR Am J Roentgenol. 173(1):245,
1999
all non-Hodgkin lymphomas and 1.5% of all ovarian
tumors
• Ovarian lymphoma typically has poor outcome
o Better than that of ovarian epithelial carcinoma
• Prognosis depends on several factors
o Laterality of ovarian involvement
▪ 1-year survival rate in unilateral disease is 77% vs.
5 46% for bilateral ovarian involvement
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OVARIAN LYMPHOMA
Ovary
acute pelvic pain shows bilateral
ovarian enlargement . Both
ovaries are homogeneous;
however, the right ovary shows
significantly lower attenuation
compared to the left ovary. There
is no ascites. A small uterus
is present anterior to the ovarian
masses. (Right) Sagittal CECT
enlarged right ovary posterior
to a small prepubertal uterus .
t
ne
e.
yn
masses with homogeneous
bg low signal intensity. (Right)
masses with homogeneous
ko
high signal intensity (relative to

pelvic muscles). There is also
an enlarged left iliac node
oo
showing similar signal intensity.

No other tumor sites were found
on PET/CT. Involvement of
regional nodes draining the
eb
ovary should not preclude the

diagnosis of primary ovarian
lymphoma.
://
tp
ht

shows homogeneous intense
enhancement of the left ovarian
mass and left iliac node .
The right ovarian mass shows
no significant enhancement.
(Right) Coronal T1WI C+ FS
intense enhancement of the left
ovarian mass with prominent
peripheral enhancement and
absent enhancement of the
right ovarian mass . The right
ovary was found to be torsed on
laparoscopy.
5
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with an abdominal mass shows
, with the larger right ovary
located anterior to the uterus
. (Right) Axial CECT in the
same patient shows a thick-
walled small bowel loop
with a dilated lumen . The
aneurysmal dilatation of the
small bowel lumen results
from infiltration of muscularis
layer with destruction of the
myenteric plexus, leading to
dilatation rather than luminal
t
narrowing.
ne
e.
yn
ovarian mass and the
aneurysmally dilated loop
bg
of small bowel . (Right)
patient obtained 1 month after
ko
resection of the small bowel

tumor shows marked increased
uptake within the right ovarian
oo
mass , as well as another

focus of small bowel tumor
that was not recognized on the
initial CECT.
eb
://
tp
ht

a 19-year-old woman
shows bilateral ovarian
enlargement . (Right)
enlargement . Note also
the circumferential thickening
of the terminal ileum . The
presence of bilateral ovarian
enlargement and small bowel
wall thickening in a young
female should always suggest
Burkitt lymphoma, which was
confirmed during surgery.
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OVARIAN LYMPHOMA
Ovary
color Doppler pelvic ultrasound
presented with palpable adnexal
masses shows an enlarged right
ovary . The ovary shows
homogeneous low echogenicity
with 1 follicle displaced
toward the periphery. (Right)
Axial transabdominal pelvic
shows an enlarged left ovary .
The ovary shows homogeneous
low echogenicity with a small
area of cystic change .
t
ne
e.
yn
(Left) Coronal T2WI FS MR in
the same patient shows slight
bg . The enlarged ovaries have
homogeneous high signal
intensity relative to the pelvic
muscles and are devoid of
ko
ovarian follicles. (Right) Axial

shows the enlarged right ovary
oo
with homogeneous high

signal intensity.
eb
://
tp
ht

patient shows an enlarged right
ovary with homogeneous
intermediate signal intensity that
is similar to that of the pelvic
skeletal muscles. (Right) Coronal
patient shows mild homogeneous
enhancement of both ovaries ,
similar to that of the myometrium
revealed follicular lymphoma.
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Ovary ENDOMETRIOMA
Key Facts
Imaging • Complications
• Cystic hemorrhagic ovarian mass with thick wall o
o
Endometriosis associated neoplasm
• < 15 cm, solitary or multiple o
Polypoid endometriosis
• Unilocular or multilocular o
Decidualization during pregnancy
• Thick fibrous capsule

Rupture of endometrioma
• No internal enhancement or Doppler flow Top Differential Diagnoses

• May contain fluid-fluid levels • Hemorrhagic functional cyst
• Mural linear or punctate calcifications • Mature cystic teratoma
• Ovaries adherent to adjacent structures • Cystic ovarian neoplasm
• Bilateral ovarian involvement in 30-50% • Fibrothecoma
• US • Ovarian abscess
o Diffuse homogeneous low-level internal echoes
Clinical Issues
• MR • Dysmenorrhea, pain, dyspareunia, bleeding, infertility
o T2 shading, T2 dark spot
o Improved detection and characterization with FS • 80% premenopausal (25-40 years of age)
o Restricted diffusion seen in about 50% of • Symptoms may be cyclical, unrelated to disease
t
severity
ne
endometriomas
e.
yn
shows an homogeneously
hypoechoic mass in the
ovary with posterior
bg
The uniform low-level internal
echoes and echogenic wall
ko
focus are typical of an
endometrioma. (Right)
Axial T2WI FSE MR in the
same patient shows mild
oo
homogeneous hypointensity
of the mass consistent with
T2 shading. Contrast its signal
eb
intensity with the simple fluid

signal of the urinary bladder
.
://
tp
ht

intensity within the mass
, which can be seen with
blood products or fat. (Right)
Axial T1WI FS MR sequence
confirms the hyperintensity
of the mass is due to
chronic repeated hemorrhage
within an endometrioma.
Septations may be seen in
endometriomas, as in this case.
T1WI fat-saturated sequence is
important in the female pelvis
MR protocol to differentiate
mature cystic teratomas (fat) &
endometriomas (blood).
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ENDOMETRIOMA
Ovary
TERMINOLOGY ▪ Can be associated with exogenous estrogen use
(tamoxifen)
Synonyms ▪ Demonstrates intense enhancement
• Endometriotic cyst ▪ Histologically similar to endometrial polyp
• "Chocolate" cyst o Decidualization during pregnancy
▪ Endometrial stromal cells within endometrioma
Definitions may respond to hormonal stimulation during
• Cystic ovarian mass resulting from repeated pregnancy
hemorrhage of endometrial tissue implants in response ▪ ↑ progesterone levels promote hypertrophy of
to hormonal stimulation endometrial stromal cells, forming vascular mural
nodules
▪ Mural nodules
IMAGING
– Solid, smooth, or papillary
General Features – Very high signal on T2WI
• Best diagnostic clue – Isointense to placenta on all sequences
– Prominent internal vascularity (flow on Doppler
o Cystic hemorrhagic ovarian mass with smooth thick
wall US, enhance on MR)
▪ US: Diffuse homogeneous low-level internal echoes ▪ Nodules resolve or regress after birth or
▪ MR: ↑ T1W1 FS and ↓ T2WI (T2 shading) termination of pregnancy
t
▪ No internal enhancement or Doppler flow ▪ CA125 levels are not helpful to differentiate from
ne
• Location malignancy; physiologically elevated in weeks
o Ovary is most frequent site of endometriosis 11-14
o Only 1% have endometriosis confined to ovary o Rupture of endometrioma
e.
▪ Most commonly occurs during pregnancy due to
• Size
rapid growth
o < 15 cm
▪ Clinically mimics rupture of hemorrhagic cyst
•
yn
Morphology
▪ Hemoperitoneum can cause peritoneal
o Solitary or multiple
inflammation and ascites
o Bilateral ovarian involvement in 30-50%
o Endometrioma infection
o May contain fluid-fluid levels
bg
▪ Most commonly occurs as complication of surgical
o Unilocular or multilocular
drainage or aspiration
o Thin or thick septations
▪ May result from contiguous spread of
o Mural linear or punctate calcifications
ko
inflammation or hematogenously in patient with

o Shape often not completely round; may have
bacteremia
angulated margins ▪ Rarely spontaneous
•
oo
Associated findings of endometriosis ▪ May be indistinguishable from uninfected

o Superficial pelvic endometrial plaques
endometrioma or appear more complex
o Deep pelvic endometriosis (solid infiltrating)
o Hematosalpinx CT Findings
eb
o Pelvic adhesions • Nonenhancing hypoattenuating ovarian mass(es)

▪ Tethering bowel • May appear solid
▪ Obliterating tissue planes • No role in diagnosis of endometrioma
://
• Complications
MR Findings
o Endometriosis-associated neoplasm
▪ Develops in 1% of women with endometriosis • T1WI
tp
▪ Manifests at earlier stage o Single or multiple homogeneous ↑ signal intensity

▪ Occurs in younger patients (SI) ovarian masses
ht
▪ Has better prognosis ▪ High signal due to intracellular and extracellular

▪ 75% occur in ovarian endometriomas; 25% occur methemoglobin
in extraovarian endometriotic lesions o Rarely can be hypointense (7% in 1 study)
▪ Ovarian carcinoma •T1WI FS
– Predominantly endometrioid (66.7%) and o Improved detection and characterization with fat
clear cell (14.8%) subtypes of epithelial ovarian suppression (FS)
cancers o Solitary ovarian mass with persistent ↑ SI on FS
▪ Borderline ovarian tumors ▪ Nonspecific; most commonly a hemorrhagic
– Mucinous (usually müllerian subtype), ovarian cyst
endometrioid, clear cell ▪ Allows differentiation from dermoid cyst
– Not malignant; no histologic evidence of o Multiple ovarian masses with persistent high SI on FS
invasion ▪ Multiplicity increases specificity for diagnosing
– Can be locally aggressive; can recur or endometriomas
metastasize ▪ Neoplastic and functional hemorrhagic cysts are
o Polypoid endometriosis more commonly solitary
▪ Polypoid masses projecting into lumina of o Hypointense capsule
•
endometriomas, from serosal surfaces or from
mucosa of bowel or bladder
T2WI
o Cyst content 5
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Ovary ENDOMETRIOMA
▪ Most commonly hypointense ▪ Hemorrhagic ovarian cysts and dermoids may also
▪ May have intermediate to high SI contents restrict on DWI
▪ T2 shading sign • Endometriosis-associated malignancy
– ↓ SI on T2 in an adnexal cyst that has ↑ SI on T1 o Enhancing mural nodule is most sensitive MR feature
– ↓ SI on T2 is usually heterogeneous, but can be ▪ 97% sensitivity
diffuse ranging from faint to complete signal ▪ 56% specificity
void ▪ Subtraction images (postcontrast minus
– May have fluid-fluid level, hypointense precontrast) facilitate visualization
dependent layer o Loss or absence of T2 shading
– Active endometriomas: More heterogeneous due ▪ Dilution of hemorrhagic cyst contents by fluid
to bleeding with each menstrual cycle secreted by tumor
– Stable endometriomas: More homogeneous, no o Mural nodule diameter > 3 cm
longer rebleeding o Enlarging cyst
– Repeated hemorrhage results in viscous contents o Ascites and peritoneal implants are rare
with high concentration of protein and iron
(iron content is 10-20x that of whole blood) Ultrasonographic Findings
– Markedly hypointense cyst content indicates • Grayscale ultrasound
hemoconcentration o Classic appearance
– Sensitivity: 68% ▪ Homogeneous, hypoechoic ovarian mass(es)
t
– Specificity: 83% ▪ Uniform low-level internal echoes
ne
▪ T2 dark spot sign ▪ Thick wall ± echogenic foci
– Discrete, markedly hypointense foci anywhere in ▪ Round shape
cyst ▪ Posterior acoustic enhancement
o May contain fluid-fluid level; hyperechoic layer is
e.
– T1 SI is isointense > hypointense > hyperintense
to cyst contents dependent
– Separate from or adjacent to wall of lesion, not o Unilocular or multiloculated with thin or thick
yn
within wall internal septations
– Average size 7.5 mm (1-14 mm) o Echogenic intracystic nodules representing adherent
– Linear/curvilinear, round/punctate, oval blood clot ± slight attenuation
bg
– Sensitivity 36%, specificity 93% (among o Cyst contents may appear solid; look for enhanced
nonenhancing hemorrhagic lesions) through-transmission
– Indicator of chronic hemorrhage; can also be o Mural linear or punctate calcification
ko
seen in hemorrhagic neoplasms o Central calcification rare, seen in postmenopausal

– Not seen in hemorrhagic functional cysts women
o Thick fibrous capsule o Rarely anechoic, mimicking functional ovarian cyst
o Ovaries adherent to adjacent structures
oo
▪ Hypointense
▪ Punctate or curved linear signal voids along cyst ▪ Ovaries remain fixed when pressure applied with
wall on susceptibility-weighted imaging transvaginal probe
•
eb
– Wall contains clusters of hemosiderin-laden Color Doppler

macrophages o Hypovascular wall
o Additional findings of endometriosis ▪ Less commonly, wall may show increased
▪ Low SI spiculated adhesive bands vascularity
://
▪ Peritoneal plaques o Intracystic nodules show no flow on Doppler

– Low-signal T2WI ± high-signal foci o Vascular mass within endometrioma may be benign,
tp
▪ Tethered bowel loops but raises concern for complicating malignancy

▪ Obliteration of cul-de-sac and organ interfaces
• • Best imaging tool
ht
T1WI C+ FS
o Variable degrees of mural enhancement, but
o Transvaginal ultrasound (TVUS) for initial evaluation
generally hypovascular o MR imaging for indeterminate masses on TVUS
o Enhancing mass within endometrioma suggests
complicating malignancy • Protocol advice
o TVUS
•DWI
▪ Apply low pulse repetition frequency (PRF) to
o Restricted diffusion is seen in about 50% of
detect flow in neoplastic nodule and differentiate it
endometriomas
from adherent blood clot
▪ Usually in cyst contents o MR imaging
o Benign mural nodules may show restricted diffusion;
▪ Fat-suppressed T1WI
however, the presence of restriction increases
– Improves detection of small endometriomas,
suspicion of malignant transformation
o Restricted diffusion is nonspecific helping to establish multiplicity
– Helps detect endometrial implants outside of
ovaries
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ENDOMETRIOMA
Ovary
– Helps differentiate from fat-containing adnexal PATHOLOGY
masses
▪ Fat suppression General Features
– Improves dynamic range of T1WI, improving • Etiology
lesion conspicuity o Seeding of endometrial tissue to ectopic locations
– Best to use chemical shift fat suppression through fallopian tubes or surgery
techniques o Metaplasia into endometrium at ectopic sites
– Caveat with STIR: Hemorrhage can have • Genetics
T1 relaxation time similar to fat and show o More common in some families
suppression
▪ Subtraction images (postcontrast minus
o Extraovarian endometriosis
precontrast) help visualize enhancing nodule ▪ Endometriotic plaque
within intrinsic high T1 signal cyst contents ▪ Fibrous adhesions
▪ Hematosalpinx
DIFFERENTIAL DIAGNOSIS o Adenomyosis
o Endometriosis-associated malignancy
Hemorrhagic Functional Cyst ▪ Develops in 1% of women with endometriosis
• Solitary ▪ Coexistence of endometriosis and tumor with
• More complex and heterogeneous content on TVUS
t
intervening transitional lesion
o Fine linear strands ("fishnet") – Transitional lesion = ectopic endometrium with
ne
o Retracting clot atypia interposed between endometrium and
• Tends to be brighter on T2, shading not typical due to adenocarcinoma
lower viscosity – This strict criteria is fulfilled by 40%
e.
• May have T2 shading, in which case T2 dark spot sign ▪ Ovarian carcinoma
and foci of susceptibility artifact in cyst wall can help – Endometrioid (66.7%) and clear cell (14.8%)
yn
differentiate endometriomas subtypes of epithelial ovarian cancers
• Hypervascular wall ▪ Borderline ovarian tumors
– Mucinous (usually müllerian subtype)
Mature Cystic Teratoma
bg – Endometrioid
• Highly echogenic attenuating component on TVUS – Clear cell
o Fluid-fluid level
▪ Hyperechoic layer is dependent in endometrioma Gross Pathologic & Surgical Features
• Bilateral in 1/3 to 1/2 of cases
ko
▪ Hyperechoic layer is nondependent in dermoid

• Fat content on MR • Rarely exceed 15 cm
o High SI area(s) on T1WI become hypointense after • Commonly covered by fibrous adhesions resulting in
oo
fat-suppression fixation to adjacent structures

• Focal calcification suggests dermoid, but does not • Cyst wall
exclude endometrioma o Thick and fibrotic
eb
o Smooth or shaggy
Cystic Ovarian Neoplasm o Brown to yellow lining
• Serous: Cyst content is more commonly simple, • Cyst contents
enhancing mural nodules/septations
://
o Semifluid or inspissated, chocolate-colored material

• Mucinous: Cyst content can overlap with o Rarely filled with watery fluid
endometrioma, typically multilocular with enhancing
• Red, brown, or white plaques of endometriosis
tp
septations
• Enhancing solid component(s) Microscopic Features
• • Ovarian endometriosis is a spectrum from simple to
ht
Ascites and peritoneal seeding if malignant

microscopically dilated glands to endometriotic cysts
Fibrothecoma
• Solid ovarian mass • Can occur anywhere in ovary, most common in cortex
• Typically shows delayed enhancement • Very superficial endometriosis occurs on ovarian
surface as nodules, irregularly shaped aggregates, or
• Low to intermediate SI on T1WI plaque-like lesions
Ovarian Abscess • Endometriotic cyst
o Epithelial and stromal lining are often attenuated or
• History indicates infection
• Significant mural vascularity
lost and replaced by granulation tissue
o Old cysts may have ossification, calcification, and old
• Evidence of surrounding pelvic inflammation
luminal blood
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4. McDermott S et al: MR imaging of malignancies arising

CLINICAL ISSUES in endometriomas and extraovarian endometriosis.
Presentation Radiographics. 32(3):845-63, 2012
• Most common signs/symptoms 5. Siegelman ES et al: MR imaging of endometriosis: ten

imaging pearls. Radiographics. 32(6):1675-91, 2012
o Dysmenorrhea 6. Lee YR: CT imaging findings of ruptured ovarian
o Pain endometriotic cysts: emphasis on the differential diagnosis
o Dyspareunia with ruptured ovarian functional cysts. Korean J Radiol.
o Irregular bleeding 12(1):59-65, 2011
o Infertility 7. Tsili AC et al: Malignant transformation of an endometriotic
• Other signs/symptoms cyst: MDCT and MR findings. J Radiol Case Rep. 5(1):9-17,
2011
o Large percentage are asymptomatic
8. Bennett GL et al: Unusual manifestations and complications
o Ruptured endometrioma resulting in acute abdomen of endometriosis--spectrum of imaging findings: pictorial
• Symptoms may be cyclical review. AJR Am J Roentgenol. 194(6 Suppl):WS34-46, 2010
• Unrelated to disease severity 9. Dujardin M et al: Cystic lesions of the female reproductive
system: a review. JBR-BTR. 93(2):56-61, 2010
Demographics 10. Tanaka YO et al: MRI of endometriotic cysts in association
• Age with ovarian carcinoma. AJR Am J Roentgenol.
o 80% premenopausal (25-40 years of age) 194(2):355-61, 2010
11. Vandermeermd FQ et al: Imaging of acute pelvic pain. Top
o 10% adolescent
t
Magn Reson Imaging. 21(4):201-11, 2010
o 2-5% postmenopausal
ne
12. Takeuchi M et al: Susceptibility-weighted MRI of
• Epidemiology endometrioma: preliminary results. AJR Am J Roentgenol.
o Higher socioeconomic group 191(5):1366-70, 2008
13. Asch E et al: Variations in appearance of endometriomas. J
e.
Natural History & Prognosis Ultrasound Med. 26(8):993-1002, 2007
• Self-limited in most patients 14. Kinkel K et al: Diagnosis of endometriosis with imaging: a
• Increasing size with menses may occur review. Eur Radiol. 16(2):285-98, 2006
yn
• Generally improves with pregnancy and menopause 15. Lee SI: Radiological reasoning: imaging characterization
• 1% rate of malignant transformation

of bilateral adnexal masses. AJR Am J Roentgenol. 187(3
Suppl):S460-6, 2006
• Women with endometriosis are 4.5x more likely to
bg
16. Fruscella E et al: Sonographic features of decidualized
develop ovarian cancer ovarian endometriosis suspicious for malignancy.
• Decidualized tissue may develop during pregnancy, 17.
Wu TT et al: Magnetic resonance imaging of ovarian
ko
resulting in solid components that mimic malignancy
cancer arising in endometriomas. J Comput Assist Tomogr.
Treatment 28(6):836-8, 2004
• Gonadotropin releasing hormone agonist (GnRH-a) 18. Sala EJ et al: Magnetic resonance imaging of benign adnexal
• Laparoscopic surgery
oo
disease. Top Magn Reson Imaging. 14(4):305-27, 2003
• Pain responds to both GnRH-a and laser surgery

19. Zanardi R et al: Staging of pelvic endometriosis based on
MRI findings versus laparoscopic classification according
• Infertility responds only to laser surgery to the American Fertility Society. Abdom Imaging.
eb
28(5):733-42, 2003
20. Glastonbury CM: The shading sign. Radiology.
21. Modesitt SC et al: Ovarian and extraovarian endometriosis-
://
Consider associated cancer. Obstet Gynecol. 100(4):788-95, 2002

• Surgery for larger lesions 22. Alcazar JL: Transvaginal colour Doppler in patients with
• Surgery for cyst with enhancing mural nodule(s) or
tp
ovarian endometriomas and pelvic pain. Hum Reprod.

16(12):2672-5, 2001
solid component
23. Woodward PJ et al: Endometriosis: radiologic-pathologic
ht
Image Interpretation Pearls correlation. Radiographics. 21(1):193-216; questionnaire

• Cystic ovarian mass(es) with low-level echoes on TVUS 288-94, 2001
• Multiple ovarian masses hyperintense on T1WI FS 24. Patel MD et al: Endometriomas: diagnostic performance of
US. Radiology. 210(3):739-45, 1999
• Solitary ovarian mass hyperintense on T1W1 FS, 25. Guerriero S et al: Tumor markers and transvaginal
hypointense on T2WI (shading) ultrasonography in the diagnosis of endometrioma. Obstet
• T2 dark spots Gynecol. 88(3):403-7, 1996
• Associated pelvic endometrial plaque, adhesions, 26. Atri M et al: Endovaginal sonographic appearance of benign
ovarian masses. Radiographics. 14(4):747-60; discussion
hematosalpinx
761-2, 1994
27. Ha HK et al: Diagnosis of pelvic endometriosis: fat-
SELECTED REFERENCES suppressed T1-weighted vs conventional MR images. AJR
Am J Roentgenol. 163(1):127-31, 1994
1. Corwin MT et al: Differentiation of ovarian endometriomas 28. Outwater E et al: Characterization of hemorrhagic adnexal
from hemorrhagic cysts at MR imaging: utility of the T2 dark lesions with MR imaging: blinded reader study. Radiology.
spot sign. Radiology. 271(1):126-32, 2014 186(2):489-94, 1993
2. Chaudhry S et al: Detection and differential diagnosis of 29. Togashi K et al: Endometrial cysts: diagnosis with MR
suspected malignant transformation of an endometrioma imaging. Radiology. 180(1):73-8, 1991
during pregnancy. BMJ Case Rep. 2013, 2013 30. Zawin M et al: Endometriosis: appearance and detection at
5 3. Khashper A et al: T2-hypointense adnexal lesions: an

MR imaging. Radiology. 171(3):693-6, 1989
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ENDOMETRIOMA
Ovary
shows a hypoechoic adnexal
mass . Although slightly
heterogeneous in echotexture,
the posterior acoustic
enhancement and echogenic
wall foci are clues to the
diagnosis of endometrioma.
complex adnexal masses .
Endometriomas are nonspecific
on CT and can mimic solid
masses or tubo-ovarian
abscesses. The preservation of
pelvic fat , lack of surrounding
t
inflammation, and clinical
ne
history help to distinguish
endometriomas.
e.
yn
shows the juxtaposition of a
classic endometrioma with
bg uniform low level internal echoes
and a thick wall against a typical
hemorrhagic functional cyst
. (Right) Transabdominal
ko

obtained 2 years later shows
evolution of the endometrioma
oo
, which now contains a

fluid-fluid level. A dependent
echogenic layer is seen in
endometriomas, as opposed to a
eb
nondependent echogenic layer in

mature cystic teratomas.
://
tp
ht

ultrasound shows a
homogeneously echogenic
left adnexal mass with a
thick wall. (Right) Longitudinal
color Doppler transabdominal
ultrasound shows no internal
blood flow in the solid-appearing
echogenic adnexal mass
. The mass and posterior
acoustic enhancement are better
visualized transabdominally,
as is often the case with large
pelvic masses. This was surgically
removed and proven to be an
endometrioma.
5
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Ovary ENDOMETRIOMA

shows bilateral endometriomas
showing the variable
appearances of T2 shading
including heterogeneous
hypointensity , near
complete signal void ,
and hypointense dependent
fluid level . (Right) Sagittal
T2WI FSE MR shows a
small hypointense focus
along the wall of 1 mass
consistent with the T2 dark
spot sign, more specific for
an endometrioma than T2
shading, as it is not seen in
t
hemorrhagic cysts. Note free
ne
fluid in the anterior cul-de-sac
and peritoneal thickening .
e.
yn
marked homogeneous
hyperintensity in all of the
bg
masses regardless of the
degree of T2 shading. Only
very rarely do endometriomas
ko
contain watery fluid,

producing low signal on T1WI.
(Right) Axial ADC map shows
oo
hypointensity of the larger

endometriomas . Diffusion
restriction may be seen in
about half of endometriomas,
eb
as in this case. Restriction seen

in the fluid component of the
cystic mass is not an indicator
of malignant transformation.
://
tp
ht

image above the level
of the endometriomas
shows high signal intensity
fluid scattered in the
peritoneal cavity. One of the
endometriomas is partially
seen . (Right) Axial T1WI
FS MR shows hyperintense
fluid in the anterior cul-de-sac
. This was due to rupture of
an endometrioma, which had
resulted in the sudden onset
of pelvic pain 2 hours prior to
this MR. Peritoneal thickening
related to irritation by blood
products is best seen on T2WI.
Note the uterus .
5
194
Obgyne Books Full
ENDOMETRIOMA
Ovary
ultrasound shows an adnexal
mass with uniform low-level
internal echoes and posterior
acoustic enhancement consistent
with an endometrioma. There
is a mural nodule within
the lesion. (Right) Longitudinal
ultrasound shows the solid mural
nodule with internal blood
flow to best advantage. Note
the uniform internal echoes
and smooth thick wall
typical of an endometrioma.
Mural nodules can be seen in
t
benign polypoid endometriosis
ne
but always raise concern for
malignant transformation.
e.
yn
homogeneous hypointensity in
an oval left adnexal mass .
bg Less commonly, T2 shading
can be homogeneous, as
demonstrated in this case. Low
T2 signal is due to the high
ko
concentration of protein and

iron in the cyst contents resulting
from repeated hemorrhage.
oo
(Right) Axial T1WI FS MR shows

that the mass is intensely
hyperintense and demonstrates
a mural nodule not apparent
eb
on the T2WI. Mural nodules may

be smooth or papillary, and may
be solid or have internal cystic
change.
://
tp
ht

shows the left adnexal mass
; however, the mural nodule
is now obscured. (Right)
Axial T1 C+ subtraction MR
shows the cystic nature of the
endometrioma and highlights
the enhancing mural nodule
. This case illustrates the
importance of subtraction images
to visualize enhancement within
the intrinsic high signal intensity
contents of an endometrioma
on T1WI. Approximately 2/3 of
mural nodules in endometriomas
represent malignancy, most
commonly endometrioid or clear
cell subtypes.
5
195
Obgyne Books Full
Ovary ENDOMETRIOMA

ultrasound in a postpartum
female shows a complex
cystic adnexal mass with
a mural nodule . (Right)
Longitudinal pulsed Doppler
marked vascularity within the
nodule with arterial blood
flow.
t
ne
e.
yn
the hyperintense cystic mass
with the single papillary
bg
projection . (Right) Sagittal
T2WI FSE MR shows the
anterior location of the adnexal
ko
mass relative to the uterus

. The mass enlarged during
pregnancy and was beginning
oo
to decrease in size post partum

at the time of this MR. The
history of prior endometrioma,
development of the mural
eb
nodule during pregnancy,

and its decrease in size
post partum are compatible
with decidualization of an
://
endometrioma.
tp
ht

due to methemoglobin in
endometriotic cysts . The
papillary nodule is obscured
by the intrinsic high T1
signal of the cyst. (Right)
demonstrates the papillary
morphology and intense
enhancement of the mural
nodule typically seen in
decidualized endometriomas
. Increased progesterone
levels during pregnancy
promote hypertrophy of
endometrial stromal cells,
forming vascular mural
5 nodules.
196
Obgyne Books Full
ENDOMETRIOMA
Ovary
a breast cancer patient on
tamoxifen therapy shows
diffuse cystic change of the
Transvaginal ultrasound in the
mass with uniform low-
level internal echoes, a smooth
thick wall, and an internal
septation consistent with an
endometrioma. There is a mural
nodule with cystic change
compatible with polypoid
endometriosis, which can be
t
seen with exogenous hormone
ne
therapy such as tamoxifen.
e.
yn
endometrioma with T2
bg shading as manifested by the
hypointense fluid level .
Cystic change in the papillary
projection is evident.
ko

shows hyperintensity within the
dominant adnexal mass, but
oo
also demonstrates a 2nd, smaller

lesion. Multiple T1 hyperintense
ovarian lesions are seen more
frequently with endometriosis
eb
than with other hemorrhagic

lesions such as physiologic cysts
and malignancy.
://
tp
ht
(Left) Axial T1 C+ subtraction

MR shows the thickened
cystic endometrium due to
tamoxifen therapy. Note the
lack of significant enhancement
within the mural nodule
or endometrioma . Cystic
change in the mural nodule
seen best on the T2WI parallels
than in the endometrium due
to tamoxifen. (Right) Axial ADC
map shows restriction within the
cyst contents but not within
the mural nodule , further
confirming benign polypoid
endometriosis due to exogenous
hormones.
5
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Ovary ENDOMETRIOSIS
Key Facts
• Presence of endometrial glands and stroma outside • Peritoneal tumor implants
of uterus, often accompanied by inflammation and • Desmoid tumor
fibrosis • Subserosal leiomyoma
Imaging • Colon cancer
• Endometrioma • Cervical cancer
• Hematosalpinx Clinical Issues
• Deeply infiltrating endometriotic implants • Dysmenorrhea, pain, dyspareunia, irregular bleeding
o Solid, ill-defined, irregular lesions on peritoneal
• Large percentage are asymptomatic
surfaces ± small cystic foci
o ↓ SI nodule on T2WI (muscular hypertrophy and • Affects 90% of women with chronic pelvic pain
fibrosis) • Affects 20-50% of women with infertility
o ↑ SI foci on T1 & T2 (dilated and hemorrhagic • 80% premenopausal, 5% postmenopausal, 10%
endometrial glands) adolescent
• Angulated tethered bowel/ovaries on T1WI and T2WI • Endometriosis-associated malignancy develops in 1%
•
t
Obliteration of organ interfaces
ne
e.
yn
(Left) Longitudinal TAS shows
a hypoechoic mass with
small cystic areas in the
posterior urinary bladder wall.
bg
The uterus is separate.
shows a hypointense mass
ko
with punctate hyperintense
foci in the posterior urinary
bladder wall. A separate
oo
hypointense lesion on
the anterior serosal surface
of the uterus causes
distortion of normal uterine
eb
flexion and irregularity of the

anterior external contour. This
is compatible with deeply
infiltrating endometriosis of the
://
anterior pelvic compartment.

tp
ht

FSE MR shows endometriotic
invasion of the bladder
wall to best advantage.
The subperitoneal location
of bladder endometriosis
makes laparoscopic
visualization difficult and
increases reliance on MR to
map the presence and size of
implants. The irregular shape
and indistinct margins of the
implant along the anterior
uterine serosa is best shown on
this image oriented along the
short axis of the uterus. (Right)
hyperintense hemorrhagic foci
5 in the bladder implant.
198
Obgyne Books Full
ENDOMETRIOSIS
Ovary
o Ovarian endometrioma
TERMINOLOGY
▪ Marker of severity of solid endometriosis
Definitions ▪ Increased risk of multifocal and intestinal disease
• Presence of endometrial glands and stroma outside by 2-3 times
o Deep infiltrating endometriosis (DIE) or solid
of uterus, often accompanied by inflammation and
fibrosis endometriosis
▪ Defined by invasion of endometrial glands and
stroma at least 5 mm beyond peritoneal surface
IMAGING
•Retrocervical endometriosis
General Features o Common; associated with vaginal/intestinal lesions
• Best diagnostic clue o Causes severe and painful symptoms; physical exam
o Endometrioma can be inadequate for extent of disease
o Deeply infiltrating endometriotic implants o Spectrum of abnormalities
▪ ↓ SI nodule on T2WI with ↑ SI foci on T1 & T2 ▪ Diffuse or focal thickening of uterosacral ligaments
o Hematosalpinx ▪ Stellate nodule at cervical insertion of uterosacral
• Location ligament (torus uterinus) ± internal cystic foci
▪ Soft tissue along posterior uterine serosal surface
o Anterior pelvic compartment
▪ Urinary bladder and urethra extending from fundus to cervix
– Infiltrative with indistinct margins
▪ Anterior cul-de-sac (vesicouterine pouch)
t
– May cause retractile retroflexion of uterus
▪ Anterior broad ligament
ne
– Typically involves outer 10% of myometrium
▪ Anterior uterine serosa
– Discontinuous with junctional zone
▪ Round ligament
o Easily recognized laparoscopically as thickening or
▪ Canal of Nuck
e.
o Posterior pelvic compartment (most common) nodularity of ligaments unless severe adhesions and
▪ Posterior cul-de-sac (pouch of Douglas, pelvic distortion obscure uterosacral ligaments
•
yn
Vaginal endometriosis
rectovaginal pouch)
o Typically associated with other lesions, usually
– Extends to middle 1/3 of vagina in 93%
▪ Posterior broad ligament retrocervical and rectal
o Thickening of superior 1/3 of posterior vaginal wall
▪ Posterior uterine serosa
bg
o Polypoid mass protruding into posterior vaginal
▪ Uterosacral ligaments
▪ Rectosigmoid colon fornix
o Middle pelvic compartment o Risk of rectovaginal fistula
ko
o Important to diagnose preoperatively due to need for

▪ Uterus
▪ Ovaries altered surgical technique
– Most common location •Rectovaginal space endometriosis
oo
– Microscopic surface implants and o Space located between posterior vaginal wall and
endometriomas anterior rectal wall below peritoneal reflection
▪ Fallopian tubes o Usually extension of retrocervical or posterior
eb
▪ Vagina vaginal lesions

o Abdominal o Easily seen on speculum exam but may be difficult to
▪ Ascending, transverse, and descending colon see laparoscopically due to subperitoneal location of
://
▪ Appendix implant
▪ Ileocecal junction o Rectovaginal septum (inferior 2/3 of rectovaginal
▪ Small bowel space) is rarely affected
tp
▪ Omentum •Fallopian tube endometriosis (30% at laparoscopy)

o Surgical scar implants o Serosal or subserosal implants (26%)
ht
▪ Cesarean section, myomectomy ▪ Hydrosalpinx

▪ Episiotomy – Tube distended with ↑ T2, ↓ T1, no enhancement
o Rare extraperitoneal sites ▪ Implants on peritoneal surface of tubes → repeated
▪ Lungs and pleura hemorrhage → fibrosis → tubal obstruction
▪ Central nervous system o Intraluminal implants (6%)
• Size ▪ Hematosalpinx
o Most plaques < 5 mm – Tube distended with ↑ SI on T1 and T2, no
o Plaques > 10 mm visible with imaging enhancement
• Morphology – Typically no T2 shading
▪ Implants on mucosal surface of tubes → cyclical
o Solid, ill-defined, irregular lesions on peritoneal
surfaces hemorrhage → tubal distention with blood
o ± small cystic foci •Alimentary tract endometriosis (12-37%)
o Extensive lesions resemble adenomyosis o Most are asymptomatic but can mimic irritable bowel
• 3 forms of pelvic endometriosis syndrome or, in severe cases, cause obstruction
o 75-90% anterior rectum and rectosigmoid colon
o Superficial peritoneal lesions (noninvasive implants)
o Appendix > ileum > cecum > descending colon
▪ Typically small and not seen on imaging
o Rectal lesions are associated with 2nd intestinal
▪ Hemorrhagic lesions may be seen on MR
▪ Black, white, or red plaques on laparoscopy lesion in 55% of cases 5
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Ovary ENDOMETRIOSIS
o Rectosigmoid lesions are associated with ileocecal o Cluster of T1 hyperintense cysts or solid ill-defined
lesions in 28% of cases lesion with cystic foci
o Implants are usually superficial, invading the serosa, •Thoracic endometriosis
but can extend to muscularis propria and submucosa o 90% have catamenial chest pain
▪ Preservation of mucosa is important feature o 70-90% involve right hemothorax
excluding primary malignancy o Pleural form
▪ Wall thickening ± luminal stenosis can result once ▪ Catamenial pneumothorax/hemothorax
muscularis propria is invaded ▪ Noncatamenial endometriosis-related
▪ Implants typically along antimesenteric border pneumothorax
o Solid homogeneous nodule with irregular margins o Pulmonary form
▪ Hypoechoic on US, ↓ SI on T2WI ▪ Catamenial hemoptysis
▪ Usually between 10- and 2-o'clock positions when ▪ Pulmonary nodules; size and morphology varies
rectum viewed in cross section throughout menstrual cycle
▪ Pyramidal shape: Base at anterior rectal wall, apex o Imaging findings are nonspecific except when
at retrocervical region pneumoperitoneum (thought to be precursor to
▪ Usually confined to serosa or muscularis propria pneumothorax) or diaphragmatic implants are seen
o "Mushroom cap" sign •Scar endometriosis (0.03-1%)
▪ Invasion of colon wall by serosal implant resembles o Typical history of palpable abdominal wall mass with
a mushroom cap on T2WI cyclical pain during menses
t
▪ Not seen with primary malignancy or metastatic o Due to seeding at time of surgery
ne
disease of colon in 1 study o Implants may be subcutaneous or invade abdominal
▪ Implant invades muscularis propria stimulating wall musculature
low signal muscular hypertrophy (gills of o Hypoechoic solid nodule on US ± flow on Doppler
e.
mushroom cap) o ↓ SI nodule on T2WI with ↑ SI foci on T1 and T2
▪ Intact overlying submucosal and mucosal layers are
Radiographic Findings
yn
high signal (skin of mushroom cap)
▪ Associated fibrosis results in convergence at serosal • IVP
aspect o Focal urinary bladder contour irregularity
o Important to assess anus to lesion distance and o Ureteral irregularity/stricture
bg
circumference of bowel loop involved •Double contrast barium enema
o Rectal lesions: MR sensitivity 76.5%, specificity o Extrinsic mass effect on bowel wall
97.9% o Foreshortened bowel segment
•
ko
Urinary tract endometriosis (20%) o Flattening or tethering of bowel wall

o Most commonly involves urinary bladder o Crenulation of bowel mucosa
▪ Full-thickness infiltration of detrusor muscle (not
CT Findings
oo
just small nodules of vesicouterine fold)

▪ Mural mass projecting into lumen with intact • Nonspecific appearance
o Complex adnexal mass; can mimic pelvic
overlying mucosa
▪ Usually midline along posterior bladder dome
eb
inflammatory disease
o Peritoneal plaques; can mimic peritoneal metastases
▪ Subperitoneal location of implants limits
visualization laparoscopically MR Findings
o Ureteral involvement is uncommon
• T1WI
://
▪ Lack of specific symptoms until obstruction occurs; o Endometriotic plaque

high risk for renal loss ▪ Intermediate SI nodule, isointense to muscle
tp
▪ ~ 47% need nephrectomy at diagnosis ▪ ± high SI foci indicative of hemorrhage in ectopic

▪ Extrinsic involvement in 80% of cases endometrial glands
– Endometriotic lesion encases ureter
•
ht
T2WI
▪ Intrinsic involvement o Endometriotic plaque
– Infiltration of muscularis layer of ureteral wall
▪ ↓ SI nodule reflecting muscular hyperplasia and
▪ Consider ureteral involvement with paracervical
fibrosis; isointense to muscle
lesions ≥ 2 cm – Rarely ↑ SI nodule due to solid glandular mass
•Round ligament endometriosis (0.3-14%)
with minimal fibrosis
o Nodular and foreshorten ligaments
▪ ± high SI foci (1-4 mm) of ectopic endometrial
o Thickening > 1 cm
glands
o Right much more commonly involved than left
▪ Protective effect of sigmoid colon
•T1WI C+ FS
o Generally hypovascular, enhancement is usually
▪ Clockwise peritoneal fluid circulation
•
delayed
Canal of Nuck endometriosis (0.5%)
o Presents with inguinal mass ± cyclical pain •Additional MR findings
o Low SI spiculated bands on T1WI and T2WI
o Angulated tethered bowel/ovaries on T1WI and T2WI
5
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ENDOMETRIOSIS
Ovary
o Obliteration of organ interfaces o Use high-frequency transducer to ultrasound
• DWI may help distinguish malignant degeneration of abdominal wall
implants o Dynamic transvaginal scanning helps localize site of
o ↑ DWI, ↓ ADC compared to myometrium or small pain and identify fibrosis/implants
bowel wall
• Sensitivity 90.3% for DIE, limited with lesions < 1.5 cm
Peritoneal Tumor Implants
• Grayscale ultrasound • High signal intensity on T2WI
o Peritoneal plaque
▪ Hypoechoic solid lesion • No hemorrhagic T1 hyperintense foci in lesions
▪ Irregular shape and indistinct margins • Ascites ± peritoneal enhancement without adhesions
▪ ± multiple bright foci Desmoid Tumor
▪ ± small cystic areas
▪ US has sensitivity of 78.5% for DIE
• No hemorrhagic T1 hyperintense foci in lesion
o "Kissing ovaries" due to adhesions causing proximity • Low SI on T2WI, delayed enhancement is
indistinguishable from scar endometriosis
of ovaries to uterus
o Negative uterine sliding sign Subserosal Leiomyoma
▪ Vaginal transducer in posterior fornix and • Well-defined round/oval lesions at serosal surface of
t
withdrawn while exerting external abdominal uterus; implants tend to be ill defined and irregular
• No cystic or punctate hyperintense foci in leiomyomas
ne
pressure with opposite hand
▪ Immobility of rectum against vaginal and uterus
indicates intervening adhesions Colon Cancer
▪ Sensitivity 85%, specificity 96% • Tumor starts in mucosa and grows outward to invade
e.
• Color Doppler outer layers of rectal/colon wall
o Generally hypovascular • Endometrial implants infiltrate colon from serosal
yn
o May be moderately vascular and show vascularity surface inward, typically sparing mucosal layer
perpendicular to long axis of plaque Cervical Cancer
• Tumor centered on cervical mucosa and extends out
bg
• Best imaging tool into parametrial tissues
• Tumor is intermediate SI on T2WI
o Diagnosis
▪ TVUS best for endometriomas with MR reserved for
ko
indeterminate cases PATHOLOGY

▪ MR is more sensitive than US for deeply infiltrating
General Features
oo
endometriosis
o Preoperative mapping of known disease • Etiology
▪ MR complements laparoscopy by identifying o Not well understood, multiple theories
extent of subperitoneal disease and lesions in • Genetics
eb
locations not readily accessible at surgery o 10x increased risk of endometriosis in women with
▪ Allows preoperative planning and preparation for affected 1st-degree relative
type and extent of surgery o Strong concordance in monozygotic twins
•
://
Protocol advice • Associated abnormalities

o Optimize sensitivity of MR for detecting hemorrhagic o Adenomyosis of uterus
o Obstructive uterine anomalies
tp
foci in small implants on T1WI

▪ Images acquired during menstrual phase o ↑ prevalence of ovarian cancer
▪ Fat saturation • 80% of lesions show cyclic changes
ht
▪ Volumetric acquisition (T1WI FS), thin sections,

and high-resolution imaging parameters
• Histologic evidence of recent or remote hemorrhage
o Full urinary bladder to prevent wall thickening due Staging, Grading, & Classification
to underdistention, facilitate identification of small • American Fertility Society staging classification
lesions, decrease uterine anteversion, and displace o Laparoscopically classified as minimal, mild,
bowel loops out of pelvis moderate, or severe disease
o Vaginal gel aids visualization of implants along o Score determined by 3 components
vagina, rectovaginal space, and retrocervical region ▪ Implants and endometriomas: Size, location, depth
o Antiperistaltic agent, if logistically possible, will help of penetration
decrease motion from bowel peristalsis ▪ Rectouterine pouch obliteration
o Larger FOV than routine female pelvis MR with care ▪ Surface extent and appearance of adhesions
not to obscure abdominal wall lesion with saturation o No correlation with symptom severity
band
5
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Ovary ENDOMETRIOSIS
Gross Pathologic & Surgical Features • Retrocervical lesions > 2 cm: Look for ureteral
• Superficial "powder burn" or "gunshot" lesions on involvement
ovaries, serosal surfaces, and peritoneum • Use T1WI with fat saturation to find hemorrhagic foci
• Common: Black or blue-black plaques or puckered and subtle plaques
lesions • Beware of ↑ SI vessels on T1WI FS mimicking
• Less common: White, yellow, red, and brown plaques hemorrhagic foci
• Bilateral ovarian involvement in 30-50% • Other etiologies of hematosalpinx to be excluded are
tubal ectopic pregnancy and fallopian tube malignancy
• Ectopic endometrial glands and stroma with SELECTED REFERENCES
surrounding muscular hyperplasia and fibrosis
1. Gui B et al: Deep pelvic endometriosis: don't forget round
ligaments. Review of anatomy, clinical characteristics, and
CLINICAL ISSUES MR imaging features. Abdom Imaging. 39(3):622-32, 2014
2. Rousset P et al: Thoracic endometriosis syndrome: CT and
Presentation MRI features. Clin Radiol. 69(3):323-30, 2014
• Most common signs/symptoms 3. Hudelist G et al: Uterine sliding sign: a simple sonographic
o Dysmenorrhea, pain, dyspareunia, irregular bleeding predictor for presence of deep infiltrating endometriosis of
o Sacral back pain with menses, perimenstrual the rectum. Ultrasound Obstet Gynecol. 41(6):692-5, 2013
4. Gidwaney R et al: Endometriosis of abdominal and pelvic
diarrhea, cramping, and dyschezia
t
wall scars: multimodality imaging findings, pathologic
o Dysuria and hematuria
ne
correlation, and radiologic mimics. Radiographics.
o Large percentage are asymptomatic 32(7):2031-43, 2012
o Symptoms may be cyclical and estrogen dependent 5. Macario S et al: The value of pelvic MRI in the diagnosis
• Clinical profile of posterior cul-de-sac obliteration in cases of deep pelvic
e.
o Affects 90% of women with chronic pelvic pain endometriosis. AJR Am J Roentgenol. 199(6):1410-5, 2012
▪ In deep infiltrating endometriosis, pain may be 6. McDermott S et al: MR imaging of malignancies arising
yn
in endometriomas and extraovarian endometriosis.
due to increased density of peritoneal nerve fibers
Radiographics. 32(3):845-63, 2012
o Affects 20-50% of women with infertility
7. Siegelman ES et al: MR imaging of endometriosis: ten
Demographics imaging pearls. Radiographics. 32(6):1675-91, 2012
bg
• Age 8. Chamié LP et al: Findings of pelvic endometriosis
at transvaginal US, MR imaging, and laparoscopy.
o 80% premenopausal (25-40 years of age) Radiographics. 31(4):E77-100, 2011
o 10% adolescent
ko
9. Coutinho A Jr et al: MR imaging in deep pelvic
o 5% postmenopausal endometriosis: a pictorial essay. Radiographics.
• Ethnicity 31(2):549-67, 2011
o Most common in Asian, followed by Caucasian, and 10. Bennett GL et al: Unusual manifestations and complications
oo
of endometriosis--spectrum of imaging findings: pictorial

least common in black population
• Epidemiology 11.
review. AJR Am J Roentgenol. 194(6 Suppl):WS34-46, 2010
Gaeta M et al: Nuck canal endometriosis: MR imaging
o Positive association with higher socioeconomic findings and clinical features. Abdom Imaging.
eb
group 35(6):737-41, 2010

o Negative association with gravidity 12. Jung SI et al: Deep infiltrating endometriosis: CT imaging
evaluation. J Comput Assist Tomogr. 34(3):338-42, 2010
://
13. Novellas S et al: Anterior pelvic endometriosis: MRI features.

• Self-limited in most patients Abdom Imaging. 35(6):742-9, 2010
• Generally improve with pregnancy/menopause 14. Yoon JH et al: Deep rectosigmoid endometriosis:
tp
• Size may increase with menses "mushroom cap" sign on T2-weighted MR imaging. Abdom
• Malignant degeneration
Imaging. 35(6):726-31, 2010
15. Faccioli N et al: Barium enema evaluation of colonic
ht
o Endometriosis-associated malignancy develops in 1% involvement in endometriosis. AJR Am J Roentgenol.

o 25% of endometriosis-associated malignancy arises 190(4):1050-4, 2008
in extraovarian sites (75% in endometriomas) 16. Ghezzi F et al: "Kissing ovaries": a sonographic sign of
▪ Endometrioid, clear cell type, or carcinosarcoma moderate to severe endometriosis. Fertil Steril. 83(1):143-7,
o Solid lesion with intermediate SI on T1 and T2 2005
17. Bazot M et al: Deep pelvic endometriosis: MR imaging for
o + enhancement, + restricted diffusion
diagnosis and prediction of extension of disease. Radiology.
Treatment 232(2):379-89, 2004
• Laparoscopic laser surgery for infertility or pain 18. Zanardi R et al: Staging of pelvic endometriosis based on
MRI findings versus laparoscopic classification according
• Gonadotropin-releasing hormone agonist (GnRH-a) for to the American Fertility Society. Abdom Imaging.
pain 28(5):733-42, 2003
19. Woodward PJ et al: Endometriosis: radiologic-pathologic
correlation. Radiographics. 21(1):193-216; questionnaire
DIAGNOSTIC CHECKLIST 288-94, 2001
20. Ha HK et al: Diagnosis of pelvic endometriosis: fat-
Image Interpretation Pearls suppressed T1-weighted vs conventional MR images. AJR
• Look for deeply infiltrating endometriotic implants in Am J Roentgenol. 163(1):127-31, 1994
patient with endometrioma
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ENDOMETRIOSIS
Ovary
(Left) Longitudinal
shows mild retroflexion of the
uterine body with an ill-
defined hypoechoic mass
along the serosal surface of the
uterus posteriorly. Note the
relationship of the cervix
to the vagina , indicating
anteflexion. (Right) Transverse
shows the irregular hypoechoic
mass with tiny internal
cystic foci . Mild curvature
of the endometrial stripe is
suggestive of distortion of the
t
uterus by the mass.
ne
e.
yn
shows a hypointense mass
with indistinct margins along the
bg posterior uterus extending from
the fundus to the cervix. This is
1 form of retrocervical deeply
infiltrating endometriosis (DIE)
ko
that typically causes retractile

retroflexion. (Right) Sagittal T2WI
FSE MR shows the infiltrative
oo
hypointense lesion with a

cystic focus extending along
the retrocervical space to the
posterior vaginal fornix . Note
eb
the vagina is filled with gel to

facilitate visualization of vaginal
and retrocervical lesions.
://
tp
ht
(Left) Axial oblique T2WI FSE MR

shows a right adnexal mass
with T2 shading & hypointense
foci along the wall,
compatible with endometrioma.
The infiltrative retrocervical
endometriotic lesion is
distorting the uterus. Although
T2 shading may be seen with
various hemorrhagic adnexal
lesions, the T2 dark spot sign
is specific for endometriomas.
(Right) Axial T1WI FS
MR shows homogeneous
hyperintensity in the right ovarian
endometrioma & high signal
hemorrhagic foci in the solid
endometriosis.
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Ovary ENDOMETRIOSIS

ultrasound shows a dilated
ureter extending into the
pelvis. (Right) Longitudinal
demonstrates the dilated ureter
terminating in a spiculated
hypoechoic mass in the
pelvis at the level of the cervix.
t
ne
e.
yn
(Left) Sagittal CECT confirms
hydronephrosis and
hydroureter . Cortical
atrophy and delayed
bg
nephrogram indicate
longstanding obstruction
with loss of renal function.
ko
(Right) Axial CECT shows

hydroureter extending to soft
tissue at the level of the lower
oo
uterus/cervix. The obstructing

mass is isodense and
indistinguishable from the
uterus and rectal wall.
eb
Displacement of gas in the

rectum is concerning for
rectal wall invasion. This CT
appearance is nonspecific and
://
concerning for cervical cancer.

tp
ht
(Left) Axial T2WI shows

a ↓ SI stellate mass
in the left retrocervical
space. The mass abuts the
cervix and rectum ;
however, it is centered at
the cervical insertion of the
uterosacral ligament. The
signal characteristics and
location are typical of DIE.
Preservation of the cervical
mucosa and stroma excludes
cervical cancer. (Right) Sagittal
T2WI shows hydroureter to
the endometriotic lesion .
Consider ureteral involvement
with retrocervical lesions > 2
cm.
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ENDOMETRIOSIS
Ovary
the same patient shows ↓ SI
nodular thickening of the right
round ligament with ↑ SI
foci within the lesion. The
normal left round ligament is
smooth and < 1 cm in thickness,
coursing anteromedial to the
iliac vessels to the inguinal canal.
Endometriosis of the right round
ligament is more common,
possibly due to the protective
effect of the sigmoid colon on
the left. (Right) Axial T1WI FS
MR shows ↑ SI hemorrhagic
foci in the left retrocervical
t
and right round ligament lesions
ne
further confirming DIE lesions.
e.
yn
(Left) Contrast enema shows
focal nonobstructive stricture
of the sigmoid colon with
bg a crenulated contour. (Right)
Axial CECT shows an ill-defined
soft tissue mass intimately
associated with the sigmoid
ko
colon , but centered in the

pericolic fat. Mass effect on the
colon and lack of an intervening
oo
fat plane are concerning for

colonic invasion.
eb
://
tp
ht
(Left) Axial T2WI in the same

patient shows the pericolic mass
is hypointense with multiple
↑ SI foci . The indistinct
margins of the lesion are
contiguous with & likely infiltrate
the wall of the sigmoid colon
. (Right) Axial T1WI FS shows
punctate ↑ SI foci within
the pericolic lesion . Note
gas blooming in the adjacent
sigmoid colon . Although the
appearance is nonspecific on CT,
the MR features are characteristic
of intestinal endometriosis. ↓ SI
on T2WI, & hemorrhagic foci
exclude peritoneal metastases in
this young female.
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Ovary ENDOMETRIOSIS

FSE MR shows a dilated
tubular hyperintense structure
in the left hemipelvis. A
similar structure is present
on the right , although
the tubular nature is not
evident on this image.
The uterus is enlarged
with multiple leiomyomas,
and a cyst is noted in
the right ovary. (Right)
of both tubular adnexal
structures compatible
t
with hematosalpinx, which
ne
in this patient is due to
endometriosis.
e.
yn
(Left) Axial T2WI shows a right
ovarian endometrioma
with T2 shading. Subtle ↓ SI
endometriotic infiltration is
bg
present along posterior uterus.
(Right) Axial T1WI FS shows
↑ SI of the ovarian mass ,
ko
confirming blood products in

an endometrioma. Punctate ↑
SI foci along uterine surface
oo
correspond to hemorrhagic
foci in the endometriotic
lesion. Fat saturation increases
sensitivity for identification of
eb
otherwise subtle endometrial

implants by displaying the
hemorrhagic foci; but, beware
of ↑ SI in blood vessels.
://
tp
ht

presenting with high-grade
colonic obstruction shows
serosal soft tissue masses
invading the sigmoid colon
shows the circumferential
and obstructive peritoneal
mass on the sigmoid
colon . Endometrial
implants can mimic
peritoneal metastatic disease,
particularly on CT where the
appearance of endometriosis is
nonspecific. Surgery revealed
endometriotic implants as well
as dense adhesions in this
patient.
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ENDOMETRIOSIS
Ovary
with remote history of cesarean
section shows 1 of multiple
endometrial implants in the
subcutaneous fat of the anterior
abdominal wall invading the
underlying rectus muscle. Note
a second implant on this
image in the right rectus muscle.
(Right) Coronal CECT is helpful
in showing the relationship of the
implants to the cesarean scar
. Endometrial tissue deposited
at the time of surgery can be in
the subcutaneous fat or rectus
sheath and at the level of the
t
incision or cranial to it.
ne
e.
yn
shows a solid subcutaneous
nodule in this patient with
bg a palpable lump and history of
remote cesarean section. (Right)
Axial T2WI FSE MR in the same
patient shows 2 hypointense
ko
subcutaneous nodules with

internal hyperintense foci .
Careful attention to the history is
oo
needed when prescribing the MR

protocol, otherwise lesions may
be obscured by the saturation
band typically used over the
eb
anterior abdominal wall, and the

small FOV uterine imaging in a
routine female pelvis protocol.
://
tp
ht

demonstrates the hyperintense
hemorrhagic foci typical
of endometriotic lesions
and helps to exclude desmoid
tumors, which can also occur
along surgical scars. (Right)
Coronal T1WI C+ FS MR
best demonstrates the spatial
relationship of the 2 nodules
. The subq cesarean scar
is not seen, but the location
of the lesions, their signal
characteristics, and surgical
history are compatible with
incisional endometriosis.
These are readily accessible to
percutaneous biopsy, which if
needed confirms the diagnosis.
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Ovary OVARIAN HYPERSTIMULATION SYNDROME
Key Facts
Terminology o T2WI: Follicular cysts are homogeneously
• Rare complication of ovarian induction for assisted •
hyperintense, with high signal ascites
US: Bilateral ovarian enlargement with multiple
reproductive techniques
anechoic cysts
Imaging o Centrally positioned echogenic stromal tissue
• Bilateral, symmetric massive ovarian enlargement o Some cysts may be complex due to hemorrhage,
• Ovarian parenchyma largely replaced by numerous containing retractile clot or lace-like linear echoes
o Pelvic ascites is present
enlarged follicular and corpus luteum cysts
• "Wheel-spoke" appearance of ovaries is classic Top Differential Diagnoses
• Concurrent ascites • Adnexal torsion with massive ovarian edema
• CT: Ovarian enlargement with multiple low-density • Polycystic ovary syndrome
• Ovarian cancer
cysts
o Ascites &/or pleural effusion present
• MR: Bilateral symmetrically enlarged ovaries with Clinical Issues
multiple simple follicular cysts
o T1WI: Cysts are hypointense, though may be • Patients with ovarian hyperstimulation syndrome
(OHSS) are at higher risk for adnexal torsion
hyperintense if hemorrhagic
• Severe OHSS may be life threatening and requires ICU
t
ne
admission
e.
yn
(Left) Transverse
a patient undergoing fertility
treatment demonstrates a
bg
massively enlarged right ovary
containing several large
follicles. Note the size of
ko
the ovary compared to the
adjacent uterus . A large
volume of pelvic ascites
is present. (Right) Transverse
oo
enlargement of the left
eb
ovary as well, which also

contains several large follicles.
Note the pelvic ascites .
://
tp
ht
(Left) Frontal chest radiograph

large right pleural effusion
. The constellation of
enlarged ovaries, ascites, and
a pleural effusion constitutes
ovarian hyperstimulation
syndrome. (Right) Transverse
a different patient undergoing
fertility therapy demonstrates
an enlarged left ovary
measuring 8.5 cm in length.
One of the follicles contains
thin, lace-like echoes ,
consistent with hemorrhage.
The right ovary appeared
similar.
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OVARIAN HYPERSTIMULATION SYNDROME
Ovary
o Bilateral ovarian enlargement
TERMINOLOGY
▪ May be difficult to completely image ovaries on
Abbreviations endovaginal US because of large size
• Ovarian hyperstimulation syndrome (OHSS) o Multiple peripheral follicular cysts of variable size
o Most cysts are anechoic
Definitions ▪ Some cysts may be complex due to hemorrhage,
• Rare complication of ovarian induction for assisted containing retractile clot or lace-like linear echoes
reproductive techniques o Centrally positioned echogenic stromal tissue
o Usually iatrogenic o Pelvic ascites is present
o Spontaneous OHSS is extremely rare o Pleural effusions and abdominal ascites in severe
cases
IMAGING • Color Doppler
o ↑ ovarian stromal Doppler signal in moderate and
General Features severe OHSS
• Best diagnostic clue o Diminished or absent flow is suspicious for torsion
o Bilateral, symmetric massive ovarian enlargement
o Ovarian parenchyma largely replaced by numerous Imaging Recommendations
follicular and corpus luteum cysts • Best imaging tool
o Ascites o US best demonstrates ovarian enlargement with
t
• Location follicular cysts and ascites
ne
o MR is useful in cases of suspected ovarian mass
o Enlarged ovaries fill adnexa, may extend into
abdomen Radiographic Findings
• Size • Pleural effusions may be seen on thoracic imaging
e.
o Ovarian enlargement ≥ 5 cm
▪ Can grow to > 20 cm
• DIFFERENTIAL DIAGNOSIS
yn
Morphology
o "Wheel-spoke" appearance of enlarged ovaries Adnexal Torsion With Massive Ovarian Edema
▪ Follicular cysts are peripherally positioned around
• Typically unilateral
bg
central core of ovarian tissue
▪ Cyst walls and intervening compressed ovarian • Enlarged ovary with diminished or absent blood flow
parenchyma compose "spokes" • Adnexal "swirl" sign
ko
CT Findings Polycystic Ovary Syndrome

• Ovarian enlargement with multiple low-density cysts • Mildly enlarged ovaries
o "Wheel-spoke" appearance • Uniform caliber small peripheral follicles
oo
o Simple follicular cysts measure fluid density Ovarian Cancer

o Hemorrhagic cysts will be higher in density
• • Multilocular ovarian mass
Central ovarian parenchyma and cyst walls enhance
• Thickened irregular septations and mural nodules
eb
o There should be no thickened irregular septations or

enhancing mural masses Hydrosalpinx
• Ascites &/or pleural effusion • Cystic mass with incomplete septations
• Separate from ovary
://
MR Findings
• T1WI Theca Lutein Cyst
tp
o Bilateral symmetrical ovarian enlargement with • Ovarian enlargement with multiple functional cysts
multiple hypointense rounded follicular cysts
o High signal may be seen seen within hemorrhagic
• Seen in early pregnancy without ovarian induction
ht
follicular cysts
• T2WI PATHOLOGY
o Bilateral homogeneous hyperintense follicular cysts
General Features
o Intermediate to low signal of centrally located
stromal tissue
• Etiology
o Hyperstimulation of ovaries by exogenous
▪ May be slightly hyperintense secondary to edema
gonadotropins
in more severe cases o Ovaries secrete vasoactive angiogenic substances
o "Wheel-spoke" appearance
o High signal intensity pelvic ascites ▪ Cause increased capillary permeability
▪ Lead to fluid shift and accumulation in
• T1WI C+
extracellular space (ascites, pleural effusion)
o "Wheel-spoke" appearance
▪ Central ovarian tissue and follicular walls enhance Staging, Grading, & Classification
o There should be no thickened irregular septations or • Classified by modified Golan scheme
enhancing mural masses o Mild (ovarian size < 6 cm)
▪ Grade I: Abdominal distension
▪ Grade II: Abdominal distension, nausea, vomiting,
• Grayscale ultrasound diarrhea 5
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Ovary OVARIAN HYPERSTIMULATION SYNDROME
o Moderate (ovarian size 6-12 cm) • Occurs during luteal phase of menstrual cycle or early
▪ Grade III: Features of mild OHSS with ascites on US; in pregnancy
weight gain • Manifestations may persist after miscarriage/induced
o Severe (ovarian size > 12 cm) abortion
▪ Grade IV: Features of moderate OHSS with clinical • Very rare in spontaneous pregnancy
evidence of ascites and pleural effusion (dyspnea) • Risk factors include
▪ Grade V: Above features with hypovolemia, o Ovaries with "necklace" sign on US at induction
hemoconcentration, coagulopathy, oliguria, shock ▪ Multiple peripherally placed cysts
o Young age (≤ 35 years) and lean habitus
o Polycystic ovarian syndrome (PCOS)
• Bilateral enlargement of ovaries o Previous OHSS
• Multiple thin-walled cysts, occasionally hemorrhagic
Treatment
• Multiple large follicular cysts lined by luteinized • Preventative
o Monitoring by US during treatment
granulosa cells
▪ Ovarian size, number of cysts, presence of ascites
• 1 or more corpora lutea o Low-dose gonadotropin protocols
• Ovarian stroma is typically markedly congested and o Prophylactic albumin may be considered
edematous
• Conservative
t
o Bed rest
ne
CLINICAL ISSUES o Cessation of hormonal treatment or decreased dose
o IV fluids ± albumin
Presentation o Supportive treatment for
e.
▪ Renal failure
o Abdominal pain ▪ Coagulation abnormalities
o Nausea, vomiting, diarrhea ▪ Hypovolemia
yn
o Abdominal distension ▪ Ascites and pleural effusions
o With increasing severity of OHSS
▪ Ascites, pleural effusion
• ICU admission necessary for severe OHSS
•
bg Usually spontaneous resolution within 10-14 days
▪ Weight gain
▪ Localized or generalized edema
• Rarely, percutaneous US-guided cyst aspiration may be
performed to alleviate pain and distention
▪ Hemoconcentration
• Surgery is necessary in cases of adnexal torsion
ko
▪ Coagulopathy
▪ Hypovolemia, oliguria
▪ Shock DIAGNOSTIC CHECKLIST
•
oo
Complications of OHSS include

o Adnexal torsion Consider
▪ Seen in up to 7.5% of cases of OHSS • OHSS in patients undergoing ovarian induction with
▪ Increased risk of torsion with OHSS and enlarged ovaries, multiple follicular cysts, and ascites
eb
subsequent pregnancy (more than OHSS alone) Image Interpretation Pearls

o Distended luteal cysts may rupture
• Bilateral symmetrically enlarged ovaries with multiple
://
Demographics follicular cysts and ascites

o Best evaluated with US
• Age
o Classic "wheel-spoke" appearance of ovary
o Reproductive age
tp
• Epidemiology • Evaluate for associated torsion in setting of acute pain

o For all patients undergoing ovarian induction
ht
▪ Mild OHSS may be present in up to 65% of cases SELECTED REFERENCES

▪ Incidence of moderate OHSS is 3-6% 1. Ackerman S et al: Ovarian cystic lesions: a current approach
▪ Severe OHSS is seen in 0.1-3% of patients to diagnosis and management. Radiol Clin North Am.
o Rates of OHSS with clomiphene induction are low 51(6):1067-85, 2013
o OHSS associated with gonadotropin induction for 2. Baron KT et al: Emergent complications of assisted
IVF are higher reproduction: expecting the unexpected. Radiographics.
33(1):229-44, 2013
Natural History & Prognosis 3. Cicchiello LA et al: Ultrasound evaluation of gynecologic
• Usually self-limiting causes of pelvic pain. Obstet Gynecol Clin North Am.
o Resolves with cessation of hormonal stimulation 38(1):85-114, viii, 2011
o Occasionally life threatening 4. Kumar P et al: Ovarian hyperstimulation syndrome. J Hum
• Complication of ovulation induction

5.
Reprod Sci. 4(2):70-5, 2011
Shanbhogue AK et al: Spectrum of medication-induced
o Follicle development is stimulated with clomiphene complications in the abdomen: role of cross-sectional
o Ovaries may be stimulated with gonadotropin imaging. AJR Am J Roentgenol. 197(2):W286-94, 2011
injection for IVF 6. Nastri CO et al: Ovarian hyperstimulation syndrome:
o Ovulation may be triggered by administration of pathophysiology and prevention. J Assist Reprod Genet.
human chorionic gonadotropin (hCG) 27(2-3):121-8, 2010
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OVARIAN HYPERSTIMULATION SYNDROME
Ovary
(Left) Transverse transabdominal
ultrasound in a patient
undergoing fertility treatment
demonstrates an enlarged right
ovary , measuring > 7 cm in
length, and containing multiple
large follicles. The left ovary had
a similar appearance. (Right)
Transverse duplex Doppler
demonstrates a low-resistance
ovarian arterial waveform upon
spectral evaluation, a typical
finding in moderate or severe
ovarian hyperstimulation.
t
ne
e.
yn
(Left) Axial CECT image
demonstrates bilateral massively
enlarged ovaries and adjacent
bg ascites . The ovaries are
replaced with innumerable
large follicles. This patient was
undergoing fertility treatment.
ko

same patient shows enlarged
ovaries and ascites . Note
oo
the "wheel-spoke" appearance

of the ovaries. The patient
also had large layering pleural
effusions (not shown). These
eb
findings are typical of ovarian

hyperstimulation syndrome.
://
tp
ht

ultrasound in a patient
undergoing fertility treatment
shows an abnormally enlarged
right ovary , measuring
7.5 cm in length. The ovary
is largely replaced by follicles
and demonstrates a classic
"wheel-spoke" appearance.
Note the adjacent pelvic
ascites . (Right) Transverse
a similar appearance to the
left ovary . Ascites is noted
as well . This patient met
diagnostic criteria for ovarian
hyperstimulation syndrome.
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Ovary POLYCYSTIC OVARY SYNDROME
Key Facts
• Polycystic ovarian morphology with clinical and • Normal ovaries
endocrinologic dysfunction • Polycystic ovaries
Imaging • Multifollicular ovaries
• ≥ 25 follicles per ovary • Pelvic congestion syndrome
• ≥ 10 mL ovarian volume Pathology
• Fulfillment of 1 criterion by 1 ovary is sufficient • Pathophysiology: Insulin resistance and
• Usually bilateral, may be unilateral hypersecretion of androgens
• Peripheral follicles, "string of pearls" Clinical Issues
• T2: Multiple small, subcapsular ↑ SI follicles, thick ↓ SI • Abnormal menstrual cycle (amenorrhea/
ovarian cortex, ↑ volume central ovarian stroma
• T1 C+: Rim enhancement of follicles oligomenorrhea)
• Hyperandrogenism (hirsutism, acne, male pattern
• Endometrial changes in 30-40%
• Endometrial thickening ± cystic change
alopecia)
• 50-65% of patients are clinically obese
• Cannot exclude atypia or endometrial carcinoma • Infertility
t
• Tend to have DM, atherogenic lipid profile, HTN, CAD
ne
e.
yn
ultrasound of the left ovary
shows multiple peripherally
located follicles with a
bg
total volume of 14 mL. (Right)
Longitudinal pulsed Doppler
ultrasound of the right ovary
ko
an enlarged ovary with a
volume of 27 mL peripherally
displaced follicles. Stromal
oo
blood flow is characteristically

increased while resistive
index is decreased in this
eb
patient with polycystic ovary

syndrome.
://
tp
ht

shows enlarged ovaries with >
25 small subcapsular follicles
per ovary, intermediate
signal central stroma , and
thickened low signal cortex
. Ovarian volumes are
calculated at 18 mL on the
right and 19 mL on the left.
FSE MR shows the "string
of pearls" configuration
of the follicles to better
advantage. MR can be useful
for obtaining accurate follicle
counts and ovarian volumes
when ultrasound image quality
suffers due to body habitus, as
5 in this patient.
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POLYCYSTIC OVARY SYNDROME
Ovary
o Multiple small subcapsular hyperintense follicles
TERMINOLOGY o Thickened low signal intensity ovarian cortex
Abbreviations o Central ovarian tissue increased in volume
• Polycystic ovary syndrome (PCOS) ▪ Low to intermediate signal intensity
▪ Reflects increased cellularity of medullary stroma
Synonyms • T1WI C+
• Stein-Leventhal syndrome o Rim enhancement of follicles
o Enhancement of highly vascularized stroma
Definitions
▪ Faster, greater enhancement and washout on time
• Polycystic ovarian morphology (PCOM) with clinical intensity curves
and endocrinologic dysfunction
• Must exclude other etiologies of hyperandrogenism Ultrasonographic Findings
and menstrual disturbances • Sensitivity 91%, specificity 100%
• Ovaries
IMAGING o 2003 Rotterdam criteria
▪ ≥ 12 FNPO threshold met by > 50% of normal
General Features young ovulatory women
• Best diagnostic clue – Sensitivity 75%, specificity 99%
o Polycystic ovarian morphology criteria ▪ ≥ 10 mL ovarian volume
t
▪ ≥ 25 follicles per ovary o 2013 Androgen Excess & PCOS Society task force
ne
▪ ≥ 10 mL ovarian volume ▪ Literature review and update of criteria
▪ Fulfillment of 1 criterion by 1 ovary is sufficient ▪ Takes into account advances in US technology
• Location ▪ FNPO threshold raised to ≥ 25
e.
o Usually bilateral, may be unilateral – Sensitivity 85%, specificity 94%
• ≥ 25 follicle number per ovary (FNPO) – Androgen-induced arrested development and
o Ranging in size from 2-9 mm accumulation of antral follicles
yn
o Whole ovary follicle count is better than single image – TVUS technique with ≥ 8 MHz transducer
count – Acknowledge estimating FNPO is challenging
o Applicable only if using modern US technology and prone to interobserver variability
bg
(TVUS, ≥ 8 MHz transducer) – Lower thresholds found in non-European, non-
• Ovarian volume ≥ 10 cm³ Caucasian populations
▪ No change in ovarian volume threshold of ≥ 10
o Ellipsoid volume formula: 0.523 x length x width x
ko
thickness mL
o Must be measured in absence of corpus luteum or – Sensitivity 81%, specificity 84%
follicle ≥ 10 mm – Reliably assessed with TAS and TVUS
oo
o Oral contraceptives decrease ovarian size – Varies by population, related to prevalence of

o Favored criteria when image quality does not allow weight excess
reliable estimate of FNPO – Varies with age, but not significantly in 20-40
eb
o Ovarian size varies with age year olds

▪ Maximum size during adolescence ▪ ↑ ovarian stromal volume due to ↑ androgen levels
▪ Relatively small change (slow ↓) between age 20 – Gives subjective impression of ↑ stromal
echogenicity
://
and 40
▪ Rapid decrease after menopause – Intrinsic echogenicity of stroma not different in
• FNPO is recommended over ovarian volume PCOS
tp
o Greater predictive power and less variability in 18-35 – Good correlation has been found between
year olds stromal volume and total ovary size; therefore,
•
ht
no need to also do stromal measurements

•
Additional findings not included in criteria
o Ovaries more spherical in shape Endometrial changes in 30-40%
o Diffuse endometrial thickening
▪ ≥ 0.7 sphericity index (ovarian width to length
ratio) ▪ Homogeneous: Proliferative endometrium, no
o > 9 follicle number per section (per image) hyperplasia on biopsy in 1 study
▪ Sonographic sensitivity 69%, specificity 90% ▪ Heterogeneous: Proliferative endometrium,
o Follicles in a peripheral distribution hyperplasia in 25% on biopsy in 1 study
o Heterogeneous endometrial thickening with cystic
▪ "String of pearls" appearance
change
CT Findings ▪ Most commonly due to prolonged proliferative
• No role in primary diagnostic evaluation phase or hyperplasia in 40%
• May show enlarged ovaries with hypodense peripheral ▪ Cannot exclude atypia or carcinoma on imaging
o Unopposed estrogen related to anovulatory cycles
follicles and enhancing central stroma
o Lack of progesterone-induced inhibition of
MR Findings
• T1WI
proliferation and lack of differentiation to secretory
endometrium
o Low to intermediate signal intensity follicles
o Ovarian stroma isointense to myometrium
• Doppler sonography
• T2WI
o ↑ stromal blood flow on color Doppler
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o ↑ caliber of stromal vessels

o ↓ stromal resistive and pulsatility index
PATHOLOGY
General Features
• Best imaging tool • Etiology
o Incompletely understood; insulin resistance may be
o TVUS is imaging modality of choice
central to etiology
▪ At least 8 MHz transducer for follicle count
o MR useful when TVUS cannot be performed or is • Genetics
o Genetic susceptibility, although inheritance pattern
technically suboptimal
• Protocol advice
•
not precisely defined
Associated abnormalities
o Timing of US imaging
o Insulin resistance
▪ Regularly menstruating women
– Scan during early follicular phase (day 3-5) ▪ More frequently glucose intolerant or diabetic
▪ Oligo/amenorrheic women (type 2)
– Scan randomly or 3-5 days after progestin- ▪ 33-40% have impaired glucose tolerance and 10%
induced withdrawal bleeding are diabetic by 4th decade
o Greater impairment of endothelial function
▪ Hypertension
DIFFERENTIAL DIAGNOSIS o Tend to have atherogenic lipid profile
o More extensive coronary artery disease compared
t
Normal Ovaries
ne
• Normal ovaries with multiple functional cysts
with age-matched controls
o Higher prevalence of carotid atherosclerosis
• Functional cysts typically vary in size and appearance o 11x increased risk of metabolic syndrome
o Presence of maturing follicles/corpus luteum cyst o ↑ risk of endometrial carcinoma
e.
o May show features reflecting previous hemorrhage ▪ Develops at younger age, often < 35 years
• Normal volume of central ovarian stroma o Breast and ovarian cancer variably associated with
•
yn
Can have normal ovarian morphology with clinical PCOS
PCOS • Pathophysiology
o Hypersecretion of androgens
Polycystic Ovaries
bg ▪ ↑ LH:FSH ratio → ovaries preferentially synthesize
• Imaging criteria same as those for PCOS
• Clinical and biochemical evidence of PCOS absent
androgen
▪ Androgen-induced arrest in antral follicle
development → failure to select dominant follicle
ko
Multifollicular Ovaries
• Incomplete pulsatile gonadotropin (GnRH) stimulation → accumulation of antral follicles 2-8 mm in size
o Insulin resistance
of ovarian follicular development
o Associated with hyperprolactinemia, hypothalamic ▪ Insulin acts synergistically with LH to enhance
oo
anovulation, weight-related amenorrhea androgen production by ovarian theca cells

o Normal level of luteinizing hormone (LH) and ▪ Insulin inhibits hepatic synthesis of sex hormone-
binding globulin
eb
testosterone
o Reduced levels of follicle-stimulating hormone (FSH) – ↑ amount of free testosterone in circulation
• Occurs in mid to late normal puberty – ↑ effect of circulating androgens
▪ Positive correlation between ovarian size and
• Imaging features
://
o Normal or slightly enlarged ovary circulating insulin levels

o Fewer follicles than PCOS: 6-10 per ovary (4-10 mm Gross Pathologic & Surgical Features
• Enlarged ovaries with thickened cortical tunica
tp
in diameter)
o Normal amount of ovarian stroma
o Distribution of cysts throughout ovary without
• Abundance of primordial follicles typically located in
ht
outer cortex
stromal hypertrophy
• Return to normal following weight gain or treatment Microscopic Features
with pulsatile GnRH, while PCOS ovaries retain their • Fibrotic thickening of tunica albuginea
appearance throughout reproductive life • Multiple cystic follicles, atretic follicles &/or
degenerating granulosa cells
Pelvic Congestion Syndrome o Hypertrophy and luteinization of inner theca cell
• Prominent ovaries, from polycystic pattern to clusters layer
of 4-6 cysts
• Enlarged uterus, thickened endometrium CLINICAL ISSUES
Presentation
o Abnormal menstrual cycle
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Ovary
▪ Amenorrhea/oligomenorrhea Image Interpretation Pearls
o Hyperandrogenism
▪ Hirsutism, acne, male pattern alopecia
• Multiple, peripheral follicles, uniform in size, arrayed
around large central stroma
o 50-65% are clinically obese
▪ Obesity is not causative, but can exacerbate Reporting Tips
metabolic and reproductive derangements • Number of follicles per ovary
o Infertility • Range of follicle sizes
o 20-30% of women with polycystic ovaries do ovulate, • Size of largest follicle
but 90% of these on closer examination will have at • Presence of corpus luteum or dominant follicle (> 10
least 1 clinical or biochemical feature characteristic mm)
of PCOS
o Raised serum concentrations of LH, testosterone, and
• Ovarian volume
androstenedione
• Clinical profile SELECTED REFERENCES
o Heterogeneous disorder with broad spectrum of 1. Dewailly D et al: Definition and significance of polycystic
clinical manifestations ovarian morphology: a task force report from the Androgen
o Classic Stein-Leventhal syndrome Excess and Polycystic Ovary Syndrome Society. Hum Reprod
▪ Extreme form in spectrum of PCOS Update. 20(3):334-52, 2014
▪ Amenorrhea, hirsutism, sterility, and obesity 2. Lujan ME et al: Updated ultrasound criteria for polycystic
t
ovary syndrome: reliable thresholds for elevated follicle
ne
Demographics population and ovarian volume. Hum Reprod. 28(5):1361-8,
• Age 3.
2013
Battaglia C et al: Two- and three-dimensional sonographic
o Reproductive-age female
and color Doppler techniques for diagnosis of polycystic
o Biochemical and ultrasound abnormalities may
e.
ovary syndrome. The stromal/ovarian volume ratio as a new
persist after menopause diagnostic criterion. J Ultrasound Med. 31(7):1015-24, 2012
• Epidemiology 4. Lee TT et al: Polycystic ovarian syndrome: role of imaging in
yn
o Most common endocrine abnormality in females diagnosis. Radiographics. 32(6):1643-57, 2012
5. Dewailly D et al: Diagnosis of polycystic ovary syndrome
of reproductive age, affecting 4-5 million females in
(PCOS): revisiting the threshold values of follicle count on
USA
bg ultrasound and of the serum AMH level for the definition of
o Prevalence: 6.6% in females of reproductive age
polycystic ovaries. Hum Reprod. 26(11):3123-9, 2011
o 80-90% of women with oligomenorrhea have PCOS 6. Barber TM et al: Patterns of ovarian morphology in
o 5-15% of reproductive age women have clinical polycystic ovary syndrome: a study utilising magnetic
ko
symptoms of PCOS resonance imaging. Eur Radiol. 20(5):1207-13, 2010

o 20% of ovulating women have sonographic findings 7. Griffin Y et al: Radiology of benign disorders of
of PCOS menstruation. Semin Ultrasound CT MR. 31(5):414-32,
oo
2010
Treatment 8. Shanbhogue AK et al: Clinical syndromes associated with
• Pharmacologic treatment ovarian neoplasms: a comprehensive review. Radiographics.
o Oral contraceptives 30(4):903-19, 2010
eb
9. Peri N et al: Sonographic evaluation of the endometrium

o Antiandrogens for hirsutism
in patients with a history or an appearance of polycystic
o Cyclic progesterone ovarian syndrome. J Ultrasound Med. 26(1):55-8; quiz
o Progestin-containing IUD 59-60, 2007
://
o Insulin sensitizing agents 10. Chang RJ: A practical approach to the diagnosis of
o Ovulation induction agents for infertility polycystic ovary syndrome. Am J Obstet Gynecol.
•
tp
Lifestyle modification to decrease body weight 191(3):713-7, 2004

o Weight loss of even 5% improves 11. Erdem CZ et al: Polycystic ovary syndrome: dynamic
contrast-enhanced ovary MR imaging. Eur J Radiol.
▪ Menstrual regularity
ht
51(1):48-53, 2004
▪ Pregnancy rates 12. Phy J et al: Transvaginal ultrasound detection of
▪ Hirsutism multifollicular ovaries in non-hirsute ovulatory women.
▪ Glucose intolerance Ultrasound Obstet Gynecol. 23(2):183-7, 2004
▪ Hyperlipidemia 13. The Rotterdam ESHRE/ASRM-Sponsored PCOS consensus
• Screen for type 2 diabetes, cardiovascular risk factors workshop group: Revised 2003 consensus on diagnostic
• Surgical management with laparoscopic diathermy or criteria and long-term health risks related to polycystic
ovary syndrome (PCOS). Hum Reprod. 19(1):41-7, 2004
laser "drilling" 14. Balen AH et al: Ultrasound assessment of the polycystic
ovary: international consensus definitions. Hum Reprod
Update. 9(6):505-14, 2003
DIAGNOSTIC CHECKLIST 15. Dolz M et al: Polycystic ovarian syndrome: assessment
Consider with color Doppler angiography and three-dimensional
• PCOM when ≥ 25 follicles per ovary or ≥ 10 mL 16.
ultrasonography. J Ultrasound Med. 18(4):303-13, 1999
Mitchell DG et al: Polycystic ovaries: MR imaging.
ovarian volume
• Follicle count varies by age and stage of menstrual cycle
Radiology. 160(2):425-9, 1986
• Ovarian volume varies by age

• Polycystic ovaries without ovulatory dysfunction or
hyperandrogenemia not considered to have PCOS
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left ovary with multiple
small peripheral follicles
and a prominent echogenic
central stroma. (Right)
shows an enlarged right ovary
with hypertrophic central
stroma and peripherally
displaced small follicles
. Despite high-resolution
imaging with an 8 MHz
transducer, many of the small
follicles cannot be resolved to
t
allow an accurate count.
ne
e.
yn
both enlarged ovaries
and distinctly demonstrates
bg
the peripherally arranged
small follicles giving the
characteristic "string of pearls"
ko
appearance of PCOS. The

central ovarian stroma
is hypointense on T2WI, as
oo
in this case. (Right) Axial

patient shows the typical rim
enhancement of the follicles
eb
. In sonographically difficult
patients, MR can provide
accurate follicle counts per
ovary, and ovarian volume.
://
tp
ht

bilateral enlarged ovaries
with the calculated volume
of 28 mL for the right ovary
and 26 mL for the left ovary.
peripheral distribution of
follicles in the left ovary
to better advantage.
However, the resolution of
CT is inadequate to perform
accurate follicle counts.
5
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Ovary
right ovary with subcapsular
hypoechogenicity . This
likely represents numerous small
peripheral follicles. However,
due to the use of a 6 MHz
transducer, only a few distinct
follicles can be resolved.
Ovarian volume was used to
diagnose PCOM in this case
due to the technical inability to
perform accurate follicle counts.
shows cystic endometrial
t
thickening , which can be due
ne
to prolonged proliferative phase
endometrium or hyperplasia.
e.
yn
female with clinical diagnosis
bg of PCOS (oligomenorrhea,
obesity) and dysfunctional
uterine bleeding shows irregular
ko
echo complex . Endometrial

biopsy showed chronic
endometritis. (Right) Axial
oo

patient shows a hyperintense
endometrial mass invading
the fundal myometrium. T2WIs
eb
have the most tumor-myometrial

contrast and therefore are best
at demonstrating depth of
myometrial tumor invasion.
://
tp
ht

that the mass is slightly
hyperintense to myometrium.
shows intense enhancement
of the endometrial mass .
Despite negative endometrial
biopsy, D&C was recommended
based on the MR findings.
Pathology showed poorly
differentiated endometrial
carcinoma, which was thought
to be due to her hyperestrogenic
state resulting from PCOS and
obesity.
5
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Ovary PERITONEAL INCLUSION CYSTS
Key Facts
Terminology • Tend to change minimally on serial imaging and
• Benign cystic pelvic mass due to nonneoplastic reactive slowly grow over time
• CT: Cystic mass without enhancing solid components
mesothelial proliferation
• Occur almost exclusively in females of childbearing • MR: Fluid signal uni- or multilocular cystic mass
age who have functioning ovaries and pelvic adhesions o Low signal intensity on T1WI
that impair absorption of peritoneal fluid o High signal intensity on T2WI
o T1WI C+ FS: No enhancing solid components
Imaging • US: Uni- or multilocular cystic mass associated with
• Uni- or multilocular cystic mass associated with a ovary
normal-appearing ovary o Cystic spaces are typically anechoic with posterior
o Ovary may be suspended centrally, resulting in acoustic enhancement
classic "spider in web" appearance o "Spider in web" appearance is classic
o Ovary may also be eccentrically located
o Ovary should not be confused with a solid nodule Top Differential Diagnoses
o Septations are smooth, thin, and minimally • Paraovarian cyst
enhancing • Ovarian cancer
• Conform to peritoneal cavity contours • Hydrosalpinx
t
o Smooth, rounded, and angular borders
ne
e.
yn
status post colectomy
and creation of a J-pouch
demonstrates an irregular
bg
fluid density collection
within the right adnexa. The
normal right ovary is seen
ko
centrally within the adnexal
collection. Note the fluid-
distended J-pouch . (Right)
oo
patient shows the right adnexal

fluid collection with the
central right ovary , which
eb
appears "entrapped" within

the peritoneal inclusion cyst
(PIC). The fluid-distended J-
pouch is again seen .
://
tp
ht

with known pelvic adhesions
demonstrates a complex
pelvic mass . The right
ovary is seen as a subtle
central soft tissue component
. (Right) Longitudinal
endovaginal ultrasound in the
a complex adnexal mass
with anechoic cystic
components. The normal right
ovary is noted centrally
and demonstrates a small
physiologic follicle . PICs
conform to pelvic spaces and
have no true walls.
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PERITONEAL INCLUSION CYSTS
Ovary
o Loculated adnexal contrast collection without free
TERMINOLOGY
spillage into pelvis
Abbreviations o Contrast collects within cystic spaces of PIC adjacent
• Peritoneal inclusion cyst (PIC) to ovary
Synonyms CT Findings
• Peritoneal pseudocyst • NECT
• Inflammatory cysts of pelvic peritoneum o Unilateral or bilateral fluid-density cystic masses
o Density of fluid may be higher than simple fluid in
• Multilocular inclusion cyst
• Entrapped ovarian cyst/syndrome cases with hemorrhage
o Thin, smooth soft tissue density septations may be
• Benign (multi) cystic peritoneal mesotheliomas
• Postoperative peritoneal cysts
visible
o Ovary may appear as a central or eccentric soft tissue
• Benign papillary peritoneal cystosis "mass"
o Calcifications are atypical
Definitions
• Benign cystic pelvic masses secondary to nonneoplastic • CECT
o Unilateral or bilateral cystic masses without
reactive mesothelial proliferation
• Occur almost exclusively in premenopausal females enhancing solid components
o Septations are smooth, thin, and minimally
who have active ovaries and pelvic adhesions with
t
impaired absorption of peritoneal fluid enhancing
ne
o "Spider in web" appearance
o Ovary adjacent to or within peritoneal inclusion cyst
IMAGING enhances and should not be confused with a solid
e.
nodule
General Features ▪ Ovarian vasculature extends to margin of ovary
• Best diagnostic clue ▪ Ovary contains small follicles &/or corpus luteum
yn
o Cystic mass with centrally located ovary entrapped/
suspended by thick irregular adhesions MR Findings
▪ Results in classic "spider in web" appearance • T1WI
– "Spider" represents ovary, centrally positioned
bgo Cystic masses with low signal intensity
within PIC ▪ Blood products may occasionally be present,
– "Web" represents radiating peritoneal adhesions resulting in high signal intensity
o May also present as a cystic mass with eccentrically o Thin, smooth septations of intermediate signal
ko
located ovary intensity

o PICs can also be seen as oblong cystic lesions o Ovary may appear as a central or eccentric soft tissue
oo
adjacent to uterus "mass"

o May be uni- or multilocular • T2WI
▪ Wall and septations are typically thin; may o Cystic masses with high signal intensity
rarely be thickened or vascularized and simulate ▪ Blood products may occasionally be present,
eb
malignancy resulting in low signal intensity

▪ Locules measure from < 1 cm to 9 cm in size o Septations are smooth, thin, and of intermediate to
o Ovarian contour may be distorted by associated low signal intensity
://
peritoneal adhesions o "Spider in web" appearance

o PICs tend to change minimally on serial imaging and o Ovary adjacent to or within peritoneal inclusion cyst
tp
slowly grow over time can easily be recognized on T2WI

o Abuts adjacent structures/organs without invasion ▪ Ovary contains small follicles &/or corpus luteum
• Location ▪ Ovarian vasculature extends to margin of ovary
ht
o Most commonly in pelvis, intimately associated with • T1WI C+

ovaries o No enhancing solid components
o May extend into abdomen if large ▪ Ovary adjacent to or within peritoneal inclusion
• Size cyst enhances and should not be confused with a
o Range: A few mm to > 20 cm solid nodule
• Morphology o Septations may demonstrate minimal smooth
o Frequently conform to peritoneal cavity contours enhancement
▪ Smooth, rounded, and angular borders
o Insinuates within peritoneal spaces between pelvic
viscera • Grayscale ultrasound
o PICs typically have little mass effect on adjacent o Uni- or multilocular cystic mass associated with
pelvic structures ovary
o No true wall ▪ Ovary may demonstrate normal follicles &/or
▪ PIC "walls" are formed by adjacent adhesions and corpus luteum
▪ Ovarian contour may be distorted by adhesions
organs
o Cystic spaces are typically anechoic with posterior
Fluoroscopic Findings acoustic enhancement
• Hysterosalpingogram (HSG) 5
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▪ Cystic loculations may occasionally contain PATHOLOGY

echogenic fluid/debris
o "Spider in web" appearance is classic General Features
▪ Ovary may also be eccentric in cystic collection
o May be "deformable" with pressure by probe
• Etiology
o Nonneoplastic reactive mesothelial proliferation
• Color Doppler causing
o Low-resistance flow can be detected within ▪ Decreased absorption of ovarian fluid by
septations due to mesothelial vessels peritoneum
▪ Gradual accumulation of locules of fluid between
• Best imaging tool peritoneal layers &/or adhesions
o Almost always accompanied by history of pelvic
o US is most commonly used modality to detect and
surgery, infectious/inflammatory process,
characterize adnexal cystic masses endometriosis, or trauma
o MR may be used in problematic cases
▪ Interval between original insult to presentation
o US and CT can be used for imaging-guided aspiration
varies from 6 months to 20 years
• PICs occur in cases where functioning ovary and
DIFFERENTIAL DIAGNOSIS peritoneal adhesions are present
o PIC contains fluid released by ovary during ovulation
Paraovarian Cyst ▪ Corroborated by presence of high concentrations
• Seen as single or multiple cystic pelvic masses within
t
of ovarian steroid hormones often seen in PIC
ne
broad ligament contents
• Often seen as cystic lesions clearly separate from a o Concurrent inflammation about PIC may also cause
normal ipsilateral ovary additional fluid exudation from peritoneum
e.
o Peritoneal fluid absorption decreases when
Ovarian Cancer
• Complex unilateral or bilateral mixed solid and cystic peritoneum is infected or adhesions are present
o Imbalance between fluid release/exudation and
yn
masses; ipsilateral ovary typically not identifiable
• In advanced ovarian cancer cases, ascites and peritoneal absorption leads to fluid collection and
PIC formation
peritoneal carcinomatosis are seen
bg
Hydrosalpinx Gross Pathologic & Surgical Features
• Oblong peritoneal inclusion cyst may mimic • Loculated pelvic cystic mass associated with ovary
o Associated with ovarian surface without
hydrosalpinx
ko
• Folded, tubular appearance of fallopian tube is typical •

intraparenchymal extension
Cyst fluid is clear or yellow serous fluid
in case of hydrosalpinx
o May also be hemorrhagic
oo
Pyosalpinx
• Occasionally, peritoneal inclusion cysts may contain Microscopic Features
echogenic fluid mimicking pyosalpinx • Locules are lined by single layer of flattened or cuboidal
• Patients are symptomatic (fever, elevated white blood mesothelial cells
eb
cell count) in case of pyosalpinx o Supported by a connective tissue layer containing

fibroblasts, eosinophils, lymphocytes, and
Follicular Cyst granulation tissue
• Simple unilocular functional cyst arising from ovary •
://
Occasionally, cuboid cells can undergo squamous

• Will resolve over time metaplasia without nuclear or cellular atypia
•
tp
Cytologic evaluation of cyst fluid is usually

Loculated Ascites
• Focal accumulation of fluid within most dependent
nonspecific/nondiagnostic
o May show inflammatory cells or reactive mesothelial
ht
portions of peritoneal cavity secondary to cells

inflammatory or malignant adhesions
• Presence of thick peritoneal enhancement is a
characteristic feature CLINICAL ISSUES
• Not intimately associated with ovary
Presentation
Mucocele of Appendix • Most common signs/symptoms
• Sterile cystic dilation of appendix o Pelvic pain
• Typically caused by obstruction of appendix by o Pelvic mass or swelling
o Pelvic discomfort
malignancy, such as appendiceal cystadenoma
• May result in pseudomyxoma peritonei if ruptured • Other signs/symptoms
• Distinct from ovary o Many cases are asymptomatic
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▪ Up to 10% of PICs may be incidentally detected • Peritoneal inclusion cysts are adherent to surface of
on imaging performed for other reasons or upon ovary but do not involve ovarian parenchyma
surgery • Peritoneal fluid accumulation between adhesions may
o Atypical symptoms may include: Back pain, early manifest complex multicystic adnexal mass on imaging
satiety, constipation, urinary frequency, dyspareunia, • Extensive adhesions, thick vascularized septations, and
infertility, dysfunctional uterine bleeding complex fluid content of PIC may mimic malignancy
• Clinical profile o In such cases, identification of normal ovaries helps
o Premenopausal females with functioning ovaries and in correct diagnosis
history of any of the following
▪ Pelvic surgery
SELECTED REFERENCES
▪ Pelvic trauma
▪ Endometriosis 1. Ackerman S et al: Ovarian cystic lesions: a current approach
▪ Pelvic inflammatory disease to diagnosis and management. Radiol Clin North Am.
o CA125 levels are similar to those of other benign 51(6):1067-85, 2013
2. Bharwani N et al: Peritoneal pseudocysts: aetiology, imaging
ovarian masses appearances, and natural history. Clin Radiol. 68(8):828-36,
▪ May be elevated in PICs associated with 2013
endometriosis 3. Patel MD et al: Managing incidental findings on abdominal
and pelvic CT and MRI, part 1: white paper of the ACR
Demographics Incidental Findings Committee II on adnexal findings. J Am
• Age
t
Coll Radiol. 10(9):675-81, 2013
ne
o Almost always presents in women of childbearing age 4. Ross EK et al: Incidental ovarian cysts: When to reassure,
(2nd and 3rd decades of life) when to reassess, when to refer. Cleve Clin J Med.
▪ Reported age at diagnosis ranges from 15-92 years 80(8):503-14, 2013
▪ Rarely diagnosed in postmenopausal patients 5. Veldhuis WB et al: Peritoneal inclusion cysts: clinical
e.
• Epidemiology
characteristics and imaging features. Eur Radiol.
23(4):1167-74, 2013
o Estimated to be present in 2-6% of surgeries for
yn
6. Ho-Fung V et al: Peritoneal inclusion cyst. Pediatr Emerg
adnexal masses Care. 27(5):430-1, 2011
▪ Under-represents true incidence 7. Saxena AK et al: Pre-pubertal presentation of peritoneal
inclusion cyst associated with congenital lower extremity
bg
venous valve agenesis. JSLS. 15(2):264-7, 2011
• No malignant potential despite occasional occurrence 8. Heilbrun ME et al: Imaging of benign adnexal masses:
of metaplasia characteristic presentations on ultrasound, computed
• Tend to grow slowly
ko
tomography, and magnetic resonance imaging. Top Magn
• Risk of recurrence is 30-50% following surgery 9.

Reson Imaging. 21(4):213-23, 2010
Lim HK et al: Sclerotherapy of peritoneal inclusion cysts: a
Treatment long-term evaluation study. Abdom Imaging. 35(4):431-6,
oo
• Typically treated conservatively 10.

2010
Moyle PL et al: Nonovarian cystic lesions of the pelvis.
o Oral contraceptives to decrease ovarian fluid Radiographics. 30(4):921-38, 2010
production by suppressing ovulation 11. Paspulati RM et al: Imaging of complications following
eb
o Gonadotropin-releasing hormone analog therapy gynecologic surgery. Radiographics. 30(3):625-42, 2010

may also be considered 12. Amesse LS et al: Peritoneal inclusion cysts in adolescent
o Pain control for symptomatic patients females: a clinicopathological characterization of four cases.
•
://
J Pediatr Adolesc Gynecol. 22(1):41-8, 2009

US- or CT-guided fluid aspiration for large symptomatic
13. Heilbrun ME et al: Imaging of benign adnexal masses:
collections characteristic presentations on ultrasound, computed
o Often via transvaginal route
tp
•
tomography, and magnetic resonance imaging. Clin Obstet
In select cases, therapies for large and symptomatic Gynecol. 52(1):21-39, 2009
PICs may include 14. Vallerie AM et al: Peritoneal inclusion cysts: a review. Obstet
ht
o Sclerotherapy following catheter insertion Gynecol Surv. 64(5):321-34, 2009

o Laser ablation 15. Omeroglu A et al: Multilocular peritoneal inclusion cyst
o Surgical resection of adhesions as more definitive (benign cystic mesothelioma). Arch Pathol Lab Med.
125(8):1123-4, 2001
therapy
16. Jain KA: Imaging of peritoneal inclusion cysts. AJR Am J
Roentgenol. 174(6):1559-63, 2000
DIAGNOSTIC CHECKLIST 17. Sohaey R et al: Sonographic diagnosis of peritoneal
inclusion cysts. J Ultrasound Med. 14(12):913-7, 1995
Consider
• PICs should be considered in patients with a cystic
pelvic mass and prior pelvic surgery or infection/
inflammation
• Diagnosis of PIC is helpful in treatment planning, as
conservative therapies are favored
• Imaging diagnosis depends on presence of normal
ovary with surrounding loculated fluid conforming to
peritoneal contours
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a complex left pelvic mass
with a linear internal
echogenic septation . The
left ovary was positioned at
the margin of the mass. (Right)
patient demonstrates the cystic
left adnexal mass . The left
ovary is seen at the anterior
margin of the mass . Note
the internal septation .
t
ne
e.
yn
(Left) Sagittal T2WI FS MR in
left adnexal cystic mass
with the ovary positioned
bg
at the periphery. This patient
was status post hysterectomy;
imaging features and patient
ko
history are consistent with

a peritoneal inclusion cyst.
oo
in the same patient shows no

significant enhancement of
the left adnexal PIC . The
left ovary at the anterior
eb
aspect of the mass enhances

normally.
://
tp
ht

a history of pelvic surgery
shows an irregular cystic
lesion adjacent to a
normal-appearing ovary
, which contains several
physiologic follicles . The
cystic collection was present
upon serial examination. Note
how a loop of small bowel
deforms the contour of
the cystic lesion. (Right) Axial
shows the hyperintense cystic
mass with a normal right
ovary positioned at the
periphery.
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Ovary
demonstrates a complex
cystic adnexal mass with a
peripherally positioned normal-
appearing ovary . Note several
thin internal septations ,
representing pelvic adhesions.
(Right) Coronal T2WI FS MR
an adnexal cystic mass
adjacent to the left ovary
with a thin internal septation
. The patient had a history of
prior hysterectomy. PICs occur
almost exclusively in the setting
of prior surgery, infection, or
t
inflammatory process.
ne
e.
yn
(Left) Sagittal T1WI C+ MR in
thin, smooth enhancement of
bg the septations , as well as the
normal left ovary . (Right)
Transverse endovaginal color
Doppler US in a patient with
ko
prior pelvic surgery shows an

irregular cystic adnexal mass .
The left ovary is positioned
oo
at the margin of the mass. The

adhesions radiating from the
ovary produce the "spider in
web" appearance, characteristic
eb
of a PIC.
://
tp
ht
(Left) Transverse endovaginal

color Doppler US in the same
patient demonstrates the
septate adnexal mass . Note
the minimal flow within a
septation due to mesothelial
blood vessels. (Right) Frontal
view from a conventional
hysterosalpingogram in the same
patient demonstrates a loculated
collection of contrast within
the left adnexa. Contrast spilled
from the left fallopian tube has
collected within a locule of
the PIC seen on ultrasound.
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a patient with endometriosis
shows a large fluid signal cyst
. The left ovary is seen
along the anterior margin of
the unilocular cyst. Within
the left ovary, there is a
rounded, slightly "shaded"
hyperintense cyst. (Right)
Sagittal T2WI FS MR in the
large posterior pelvic cyst
and peripherally positioned
left ovary . Note how this
PIC fills and conforms to pelvic
t
spaces.
ne
e.
yn
posterior pelvic PIC to
be isointense to the pelvic
bg
musculature. Within the
left ovary at the anterior
margin of the PIC, there
ko
is a rounded hyperintense
cyst that showed a
"shaded" appearance on
oo
T2WI, consistent with an

ovarian endometrioma. Note
the uterus . (Right) Sagittal
eb
patient shows the unilocular

PIC to be nonenhancing.
The left ovary at the
anterior margin demonstrates
://
normal enhancement.
tp
ht

inflammatory bowel disease
shows a complex adnexal mass
with internal septations
. Note the inferior pole of
the ovary at the margin of
the complex mass . (Right)
patient shows the cystic
adnexal mass adjacent to
the left ovary . Note the thin
internal septation radiating
from the ovary, representing a
pelvic adhesion.
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Ovary
(Left) Axial T2WI MR
demonstrates a large, septate,
right adnexal mass . The
normal-appearing right ovary
is positioned at the periphery.
Note how the PIC insinuates
throughout the pelvic spaces,
with the borders being formed
by pelvic adhesions and adjacent
organs. (Right) Sagittal T2WI MR
in the same patient demonstrates
the eccentric ovary and
thin internal septations
within the PIC. The septations
radiating from the ovary produce
the classic "spider in web"
t
appearance.
ne
e.
yn
enhancement of the normal
bg right ovary as well as
smooth enhancement of
the thin septations . The
enhancing ovary should not be
ko
confused for a mural nodule

within a presumed cystic pelvic
malignancy. Note the uterine
oo
fundus . (Right) Sagittal T1WI

demonstrates enhancement
of the normal ovary and
eb
thin septations . There is no

suspicious mural nodularity
or mass-like enhancement
otherwise.
://
tp
ht

with a history of total colectomy
shows a large complex cystic
pelvic mass involving both
adnexa. The ovaries are
contained within this lesion.
Note the follicular cyst within
the left ovary . (Right) Axial
again demonstrates the large
cystic pelvic mass , partially
surrounding the left ovary .
With a history of pelvic surgery
in a premenopausal patient, a
PIC is the most likely diagnosis.
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Ovary OVARIAN VEIN THROMBOSIS
Key Facts
Terminology o T1WI C+: Filling defect within vein
o MRV: No signal within thrombosed ovarian vein
• Thrombosis of an ovarian vein, typically associated • US: May be difficult to evaluate entirety of ovarian vein
with puerperal infection
secondary to overlying shadowing bowel gas
Imaging o Tubular structure in adnexa represents thrombosed
• Enlarged tubular retroperitoneal structure extending ovarian vein
o Partial or absent flow within dilated vein on color
cephalad from adnexa along expected course of
ovarian vein Doppler evaluation
• Usually involves right ovarian vein (80-90%)
• NECT: Hyperdense tubular thrombus along course of
• Appendicitis
ovarian vein with surrounding inflammation
• CECT: Enlarged ovarian vein with low-attenuation • Hydrosalpinx/pyosalpinx
central filling defect • Dilated ureter
• MR
Clinical Issues
o T1: Intermediate to high signal intensity
intraluminal clot within dilated ovarian vein • Commonly seen in postpartum patients with
o T2: Intermediate to high signal intensity abdominal pain and fever despite antibiotics
• If left untreated, OVT can progress to pulmonary
t
intraluminal clot
ne
embolism, septic emboli, death
e.
yn
with persistent fevers and
abdominal pain status post
cesarean section shows a
bg
dilated right ovarian vein filled
with thrombus . There are
surrounding inflammatory
ko
changes. Note the normal
adjacent ureter . (Right)
Reconstructed coronal
oo
demonstrates thrombus
distending the right ovarian
vein. Note the small amount
eb
of thrombus extending into the

IVC lumen . This is a classic
appearance of puerperal
ovarian vein thrombosis
://
(OVT).
tp
ht

with a coagulopathy and
vague abdominal pain
demonstrates a subtle filling
defect within the left
ovarian vein. (Right) Coronal
demonstrates subtle filling
defects within both
ovarian veins. Bilateral OVT
is relatively rare; most cases
of OVT occur within the right
ovarian vein.
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OVARIAN VEIN THROMBOSIS
Ovary
TERMINOLOGY • CT venography
o No enhancement of affected ovarian vein
Abbreviations • Sensitivity of CT in diagnosis of OVT reported as up to
• Ovarian vein thrombosis (OVT) 100%
Synonyms MR Findings
• Gonadal vein thrombosis • T1WI
• Ovarian vein thrombophlebitis o Intermediate to high signal intensity intraluminal
clot within dilated ovarian vein
• Thrombosis of ovarian vein, typically associated with o Intermediate to high signal intensity intraluminal
puerperal infection clot
▪ May have thin dark hemosiderin rim
IMAGING • T1WI C+
o Filling defect within vein
General Features o Enhancement of vessel wall
• Best diagnostic clue o Inflammation and patchy enhancement of
o Enlarged tubular retroperitoneal structure extending surrounding fat
cephalad from adnexa along expected course of • MRV
t
ovarian vein o No signal within thrombosed ovarian vein
ne
▪ Central nonenhancing thrombus o Consider using a blood pool agent for post-contrast
– May be occlusive or nonocclusive MRV
▪ Enhancement of venous wall ▪ Contrast remains in intravascular space longer
•
e.
▪ Perivascular inflammation and fat stranding Steady-state free precession ([SSFP] bright blood
▪ May involve entirety of ovarian vein, extending sequence)
to infrarenal inferior vena cava (IVC) on right and o Absent signal within affected ovarian vein
yn
renal vein on left
– Anterior to psoas muscle
• Sensitivity of MR in diagnosis of OVT reported as up to
92%
• Location
bg
o Usually involves right ovarian vein Ultrasonographic Findings
▪ 80-90% of patients present with right OVT • Grayscale ultrasound
▪ 6% of patients present with left OVT o May be difficult to evaluate entirety of ovarian vein
ko
▪ 14% of patients have bilateral involvement secondary to overlying shadowing bowel gas
• Size ▪ Sensitivity of US in diagnosis of OVT reported as up
o Range from short-segment partially occlusive to 52%
▪ Attention should be focused along course of
oo
thrombus to complete occlusion of entire ovarian

vein ovarian veins anterior to psoas
o Ovarian vein is often enlarged/dilated o If seen, OVT manifests as dilated tubular structure in
•
eb
Morphology adnexa
o Round, tubular ▪ Extends cephalad along lateral aorta or IVC
o Vein is enlarged with central thrombus
CT Findings ▪ Variable echogenicity based on age of thrombus
://
• NECT o IVC and left renal vein should be evaluated for filling
o Hyperdense tubular thrombus along course of defects/thrombus
•
tp
ovarian vein Color Doppler

o Surrounding fat stranding and inflammation o Partial or absent flow within dilated vein
• o May see increased flow around vein indicative of
ht
CECT
o Enlarged ovarian vein with low-attenuation central inflammation
filling defect • Negative or equivocal US should prompt further
▪ May see sharply defined thin enhancing wall evaluation with CT or MR
▪ Produces targetoid appearance on axial imaging
o Perivascular fat stranding suggests thrombophlebitis
o Can extend into IVC or left renal vein • Best imaging tool
o CT is modality of choice due to lower cost, wide
▪ Mixing artifact within ovarian vein at level of IVC
availability, high sensitivity
or renal vein may make superior extent of clot
o MR useful in patients with iodinated contrast allergy
difficult to ascertain
o Imaging pitfall: Right ovarian vein and to reduce radiation exposure in younger patients
pseudothrombosis • Protocol advice
o Venous phase imaging is necessary to make diagnosis
▪ Asymmetric ovarian vein enhancement, with left
more dense than right and reduce artifacts
▪ Secondary to early reflux of contrast medium into ▪ CT or MR obtained too early after contrast
left ovarian vein administration will result in limited venous
o Follow ovarian vein to IVC or left renal vein to enhancement and indeterminate results
distinguish it from ureter
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DIFFERENTIAL DIAGNOSIS – Limited adventitial sheaths of ovarian veins

make them vulnerable to compression
Appendicitis ▪ Extensive communication between ovarian veins
• Symptoms may mimic OVT, but initial pain is and vaginal/uterine venous plexuses allow for easy
periumbilical that moves to right lower quadrant spread of infection
• Short tubular abnormality connects to cecum; patent – Ascending puerperal infection is thought to be
right ovarian vein key factor in development of OVT
▪ Preponderance of right-sided puerperal OVT is
Hydrosalpinx/Pyosalpinx thought to be due to several factors
• Tubular structure with thickened longitudinal folds – Reflux of blood into left ovarian vein is thought
and echogenic luminal contents to limit spread of infection and reduce stasis
• Patent ovarian vein is identifiable – Postpartum uterus is more commonly dextro-
Hydroureter positioned, causing compression of right ovarian
• Follow ureter from collecting system to urinary bladder vein
– Right ovarian vein is longer
to distinguish from ovarian vein
o Other predisposing conditions
Thrombosis of Duplicated IVC ▪ Pelvic inflammatory disease
• Duplicated IVC originates from left common iliac vein ▪ Inflammatory bowel disease (Crohn disease,
ulcerative colitis)
t
Adnexal Torsion ▪ Gynecologic surgery
• Enlarged heterogeneous avascular ovary with free
ne
– Commonly seen after hysterectomy and
intraperitoneal fluid salpingo-oophorectomy
• Normal ovarian vein is identifiable ▪ Malignancy
e.
Broad Ligament Hematoma or Phlegmon ▪ Chemotherapy
▪ Hypercoagulable disorders (lupus anticoagulant,
• Heterogeneous mass-like area in region of broad
yn
ligament protein S deficiency, factor V Leiden mutation)
▪ Hormone therapy
• May represent septic pelvic thrombophlebitis ▪ Trauma
• Normal ovarian vein is identifiable ▪ Nephrotic syndrome
bg
Necrotic Lymphadenopathy o Rare reports of cases without known etiology
• Necrotic retroperitoneal lymphadenopathy may be o May represent progression of septic pelvic
thrombophlebitis
confused with thrombosed ovarian vein
ko
• Lymphadenopathy is not tubular; multiplanar ▪ Inflammatory process secondary to thrombosis

and infection of small pelvic venous vessels
reformatted images help in correct diagnosis
• Normal ovarian vein is identifiable – Small vessel thrombi are typically not visualized
oo
on imaging
▪ Secondary to postpartum or postprocedural
PATHOLOGY infection
▪ Propagation of infection/thrombophlebitis to
eb
General Features
• Etiology involve ovarian vein results in OVT
o Most commonly associated with pregnancy and Gross Pathologic & Surgical Features
• Thrombosed, distended ovarian vein
://
puerperium
▪ Increased risk factors for thrombosis at delivery
tp
(typically resolve 2-6 weeks after delivery)

– Hypercoagulability: Pregnancy and puerperium CLINICAL ISSUES
associated with increased levels of factors I, II, Presentation
ht
VII, IX, and X and increase in platelet adhesion

– Alterations in vein endothelium: Secondary
o Common triad
to high estrogen levels, surgical insult, &/or ▪ Lower abdominal or flank pain
infection – May radiate to groin or upper abdomen
▪ Stasis of blood flow ▪ Fever 48-96 hours after delivery (41% of cases)
– Ovarian venous blood flow increases up to 60x ▪ Palpable rope-like abdominal mass (50-67% of
during pregnancy and causes 3x increase in size cases)
of ovarian vein – May be up to 8-10 cm in size
– Postpartum venous velocity drops sharply after o Typical patient presents with a persistent postpartum
delivery and causes venous collapse and stasis of fever despite antibiotic therapy
flow ▪ Often accompanied by rigors
– Compression of pelvic veins by enlarged gravid/
postpartum uterus
o Nausea and vomiting
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Ovary
o Malaise • For cases with clot extension into IVC or renal vein,
o Dyspnea anticoagulation regimen mirrors that for pulmonary
o Tachycardia embolism
o Ileus
o Seen early in puerperium; most within 10 days of
delivery Consider
▪ Infection/endometritis is present or suspected in • OVT in postpartum patients with fever unresponsive to
majority of puerperal OVT antibiotics
o May be asymptomatic, especially in cases secondary
to malignancy or surgical intervention Image Interpretation Pearls
o Leukocytosis • Enlarged, well-defined, tubular structure with central
o Elevated C-reactive protein low attenuation along expected course of ovarian vein
o Blood cultures typically negative
Demographics SELECTED REFERENCES

• Age 1. Adesiyun AG et al: Postpartum ovarian vein thrombosis:
o Usually of childbearing age when puerperal in nature incidental diagnosis at surgery. Case Rep Obstet Gynecol.
o Older patients when associated with malignancy 2014:898342, 2014
t
2. Gakhal MS et al: Ovarian vein thrombosis: analysis of
Epidemiology
ne
patient age, etiology, and side of involvement. Del Med J.
o 1:500 to 1:2,000 deliveries 85(2):45-50; quiz 59, 2013
▪ Seen in 0.018-0.05% following vaginal delivery 3. De Stefano V et al: Abdominal thromboses of splanchnic,
▪ Seen in 0.1-2% after cesarean section renal and ovarian veins. Best Pract Res Clin Haematol.
e.
– 1-2% following cesarean section complicated by 25(3):253-64, 2012
endometritis 4. Sharma P et al: Ovarian vein thrombosis. Clin Radiol.
▪ 0.7% of twin vaginal deliveries 67(9):893-8, 2012
yn
▪ Seen in up to 1:200 cases of febrile abortion
5. Verde F et al: One not to miss: ovarian vein thrombosis
causing pulmonary embolism with literature review. J
Natural History & Prognosis Radiol Case Rep. 6(9):23-8, 2012
• Overall good if recognized and treated early
bg
6. Virmani V et al: Ultrasound, computed tomography, and
magnetic resonance imaging of ovarian vein thrombosis in
o Spontaneous resolution may be seen in some patients
obstetrical and nonobstetrical patients. Can Assoc Radiol J.
(e.g., malignancy) 63(2):109-18, 2012
•
ko
If there is a delay in diagnosis, may result in 7. Cura M et al: What is the significance of ovarian vein reflux
disseminated infection, sepsis, pulmonary emboli, detected by computed tomography in patients with pelvic
death pain? Clin Imaging. 33(4):306-10, 2009
o Pulmonary embolism seen in 13-33% of cases 8. Karaosmanoglu D et al: MDCT of the ovarian vein:
oo
o Death in up to 4% of cases of OVT normal anatomy and pathology. AJR Am J Roentgenol.
• Can cause ipsilateral ureteral obstruction when 9.

192(1):295-9, 2009
Kominiarek MA et al: Postpartum ovarian vein thrombosis:
thrombosed vein compresses ureter
eb
•
an update. Obstet Gynecol Surv. 61(5):337-42, 2006
Recurrent OVT is relatively uncommon (reported as 3 10. Wysokinska EM et al: Ovarian vein thrombosis: incidence of
per 100 patient-years) recurrent venous thromboembolism and survival. Thromb
o Similar to rates of recurrent DVT Haemost. 96(2):126-31, 2006
://
o May be seen in ipsilateral, contralateral, or bilateral 11. Takach TJ et al: Ovarian vein and caval thrombosis. Tex
ovarian vein Heart Inst J. 32(4):579-82, 2005
o Typically occurs within 2 months of original OVT 12. Leyendecker JR et al: MR imaging of maternal diseases of the
tp
• Testing for underlying thrombophilias may be

abdomen and pelvis during pregnancy and the immediate
postpartum period. Radiographics. 24(5):1301-16, 2004
indicated in patients with puerperal OVT
ht
13. Morales-Rosello J et al: Postpartum ovarian vein thrombosis

Treatment with positive lupus anticoagulant. Int J Gynaecol Obstet.
• Broad-spectrum antibiotics with anticoagulation, 14.

87(2):163-4, 2004
Prieto-Nieto MI et al: Acute appendicitis-like symptoms as
though no standard treatment protocol exists initial presentation of ovarian vein thrombosis. Ann Vasc
o Broad-spectrum antibiotics for 7-10 days Surg. 18(4):481-3, 2004
o Anticoagulation with heparin, low molecular weight 15. Benfayed WH et al: Detection of pulmonary emboli
heparin, &/or warfarin resulting from ovarian vein thrombosis. AJR Am J
• IVC filter may be considered in patients with
16.
Roentgenol. 181(5):1430-1, 2003
Bennett GL et al: Gynecologic causes of acute pelvic pain:
contraindication to anticoagulation or IVC/renal vein
spectrum of CT findings. Radiographics. 22(4):785-801,
involvement
• Surgical intervention (vein interruption/ligation) for 17.
2002
Kubik-Huch RA et al: Role of duplex color Doppler
patients who fail medical therapy, cases complicated by ultrasound, computed tomography, and MR angiography in
abscess, or when anticoagulation is contraindicated the diagnosis of septic puerperal ovarian vein thrombosis.
• If incidental finding in asymptomatic patients, usually Abdom Imaging. 24(1):85-91, 1999
no need for therapy
o Typically not treated if secondary to malignancy or
after hysterectomy
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(Left) Axial CECT in

a postpartum patient
demonstrated a nearly
occlusive filling defect
within the right ovarian vein,
with a thin rim of contrast
seen at the periphery. (Right)
patient demonstrates the
nonocclusive filling defect
within the right ovarian vein.
Note the enlarged fluid-filled
uterus , consistent with
recent postpartum status. Most
cases of OVT are puerperal in
nature.
t
ne
e.
yn
(Left) Axial CECT of the
chest in the same patient
shows a filling defect
within the pulmonary artery
bg
supplying the lateral segment
of the right lower lobe.
Pulmonary embolism is
ko
a known complication of
OVT. (Right) Axial CECT in
a different patient shows a
oo
dilated right ovarian vein

with surrounding inflammatory
change. There is a subtle
central nonocclusive filling
eb
defect. This patient had fevers

and abdominal pain refractory
to antibiotic therapy following
recent delivery.
://
tp
ht

patient, obtained slightly
more cephalad, shows a
small amount of nonocclusive
thrombus within the
IVC at the level of the right
ovarian vein ostium. (Right)
patient demonstrates thrombus
throughout the right
ovarian vein with surrounding
inflammatory change and
extension into the IVC .
Note the slightly enlarged
uterus , reflecting recent
postpartum status.
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Ovary
(Left) Axial NECT demonstrates a
rounded hyperattenuating focus
anterior to the right psoas
with surrounding fat stranding
and inflammation. This patient
was status post recent vaginal
delivery with abdominal pain
and fevers. Note the enlarged
uterus . (Right) Coronal NECT
tubular hyperdensity along
the expected course of the right
ovarian vein, consistent with
OVT. On a noncontrasted study,
OVT will appear hyperdense.
Note the enlarged uterus .
t
ne
e.
yn
status post cesarean section
shows a dilated right ovarian vein
bg . There is central hypodense
nonocclusive thrombus,
consistent with OVT. (Right)
ko
obtained at a more cephalad

level shows extension of the clot
superiorly . If not recognized
oo
and promptly treated, OVT can

lead to pulmonary embolism and
disseminated infection and can
prove fatal.
eb
://
tp
ht
(Left) Coronal CECT

demonstrates a filling defect
within the right ovarian vein with
rim-like enhancement, consistent
with OVT. (Right) Sagittal CECT
dilated tubular peripherally
enhancing structure within
the right adnexa, consistent with
pyosalpinx. The right ovarian
vein again demonstrates a central
tubular hypodensity with a rim of
enhancement , consistent with
OVT. Inflammatory conditions
such as pelvic inflammatory
disease (PID) are associated with
OVT.
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Ovary PELVIC CONGESTION SYNDROME
Key Facts
Terminology • Prominent myometrial arcuate vessels maybe present
• Noncyclical chronic pelvic pain caused by dilated veins • Retrograde ovarian venography (patient in semierect
in uterus, broad ligament, and ovarian plexus position with Valsalva maneuver performed as needed)
• Occasionally pelvic varices communicate with vulval Pathology
and lower extremity varicosities
• Chronic dull pelvic pain, pressure and heaviness: • Not well understood but related to physiologic increase
in blood flow in pelvic veins during puberty and
Result of dilated tortuous and congested veins caused
pregnancy
by retrograde flow through incompetent ovarian vein
• Primary valvular deficiency
•
valves
• Underdiagnosed treatable cause of chronic pelvic pain Hormonal vasodilation
• "Nutcracker" phenomenon: Left renal vein entrapment
Imaging between aorta and superior mesenteric artery
• Varices may extend laterally to broad ligament &/or • Other obstructing anatomic anomalies: Left ovarian
inferiorly to communicate with paravaginal venous vein obstruction by retroaortic left renal vein or right
plexus common iliac artery
• ≥ 4 ipsilateral tortuous parauterine veins of varying
caliber, at least 1 of which is > 4 mm in maximum
t
diameter, or ovarian vein diameter > 8 mm
ne
e.
yn
(Left) Sagittal CECT centered
in the pelvis in a 25 year
old with chronic pain shows
enlarged myometrial
bg
and cervical arcuate
vessels suggestive of pelvic
congestion. (Right) Axial
ko
shows enlarged myometrial
and cervical arcuate
vessels as well as left gonadal
oo
varix suggestive of pelvic

congestion.
eb
://
tp
ht

MR in a patient with pelvic
congestion syndrome shows
engorged myometrial vessels
and large gonadal vessels
bilaterally . (Right) Coronal
MRA in the same patient with
pelvic congestion syndrome
shows an enlarged left gonadal
vessel .
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PELVIC CONGESTION SYNDROME
Ovary
o High signal intensity ovarian &/or parauterine veins
TERMINOLOGY
Abbreviations Ultrasonographic Findings
• Pelvic congestion syndrome (PCS) • Grayscale ultrasound
o Transvaginal ultrasound (TVUS): 3 criteria
Synonyms ▪ Tortuous pelvic vein with a diameter > 4 mm (some
• Pelvic venous incompetence, pelvic vein syndrome, investigators use > 5 mm)
pelvic varices ▪ Slow blood flow (~ 3 cm/sec)
▪ Dilated arcuate veins in myometrium that
Definitions communicate with enlarged gonadal varices
• Noncyclical chronic pelvic pain caused by dilated veins • Color Doppler
in uterus, broad ligament and ovarian plexus o Large venous structures engorging uterus and ovaries
o Sidewall, paravaginal, and internal iliac varicosities
o If vulvar varices, loud "reflux" with Valsalva
may be present
o Occasionally pelvic varices communicate with vulval maneuver
o For "Nutcracker" syndrome: Color flow in gonadal
and lower extremity varicosities
•
and retroperitoneal collaterals
1st described by Richet in 1857 o Variable color Doppler waveform with Valsalva
o Chronic dull pelvic pain, pressure and heaviness:
maneuver
Result of dilated tortuous and congested veins caused
t
by retrograde flow through incompetent ovarian vein
• Retrograde ovarian venography (patient in semierect
ne
valves
• Underdiagnosed treatable cause of chronic pelvic pain position with Valsalva maneuver performed as needed)
o Ovarian vein > 8-10 mm
o Pelvic, gonadal varices found in approximately 1/2 of
o Uterine venous engorgement
e.
women with chronic pelvic pain
o Congestion of ovarian plexus
o Filling of pelvic veins across midline &/or filling of
yn
IMAGING vulvovaginal and thigh varicosities
bg
o Dilated and tortuous parauterine tubular structures o Color and Doppler TVUS
on contrast venography, ultrasound, CT, &/or MR
▪ Engorged myometrial arcuate vessels
• Protocol advice
o IF TVUS is equivocal or nondiagnostic
•
ko
Varices may extend laterally to broad ligament &/or ▪ Noninvasive: MR or CECT

inferiorly to communicate with paravaginal venous ▪ Invasive: Retrograde ovarian vein venography
plexus
•
oo
Most cross-sectional studies are not performed erect;

therefore, subjective assessment by radiologist is DIFFERENTIAL DIAGNOSIS
important for final diagnosis
Pelvic Lymphadenopathy
eb
CT Findings • Soft tissue masses that are not tubular and do not
• CECT enhance in similar fashion to pelvic venous structures
o ≥ 4 ipsilateral tortuous parauterine veins of varying
Hydrosalpinx
://
caliber, at least 1 of which is > 4 mm in maximum

• Dilated anechoic fallopian tube without flow
diameter, or ovarian vein diameter > 8 mm
o Prominent myometrial arcuate vessels maybe present • Pyosalpinx may have low level echogenic debris
tp
MR Findings Arteriovenous Malformation

• T1WI • Congenital or acquired condition in uterus or
ht
o Serpentine flow void parauterine tissues, not purely venous

• T2WI • CECT or CEMR: Briskly enhancing soft tissue masses
versus delayed enhancement of pelvic varices in pelvic
o Serpentine flow void
congestion
o May have high or heterogeneous signal intensity
because of relative slow flow in dilated veins
o Same diagnostic criteria as CECT PATHOLOGY
▪ ≥ 4 ipsilateral tortuous parauterine veins of
General Features
• Etiology
varying caliber, at least 1 of which is > 4 mm in
maximum diameter, or ovarian vein diameter > 8
mm o Not well understood but related to physiologic
• T1WI C+ increase in blood flow in pelvic veins during puberty
o Delayed enhancement of dilated and tortuous and pregnancy
o Multifactorial: Possible factors
involved veins
▪ Around uterus and ovary and may extend into ▪ Primary valvular deficiency
broad ligament, pelvic sidewall, and paravaginal ▪ Hormonal vasodilation
venous plexus
• MRV 5
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Ovary PELVIC CONGESTION SYNDROME
▪ "Nutcracker" phenomenon: Left renal vein o Coil embolization: Significant decrease in (50-80%)
entrapment between aorta and superior mesenteric in pain without notable impact on menstrual cycle;
artery 60% report complete resolution of symptoms
▪ Other obstructing anatomic anomalies: Left • Resection or ligation (open surgical or laparoscopic
ovarian vein obstruction by retroaortic left renal management)
vein or right common iliac artery o Increased incidence of morbidity compared with
▪ Psychomotor venodilation embolic therapy
o Risk factors: Hereditary, pelvic surgery, retroverted o Bilateral ligation: Pilot study with complete
uterus, history of varicose veins remission of pain and absence of varicose veins for 1
• Genetics year
o Hereditary risk factors have been suggested • Hormonal manipulation (pharmacologic ovarian
• Incompetent ovarian &/or internal iliac veins are suppression)
usually present but not causative
• Pelvic/ovarian varices can be seen in asymptomatic DIAGNOSTIC CHECKLIST
women
o Prevalence in general population approaches 10% Consider
o Passive reflux into left gonadal vein is common
• PCS in women with noncyclic chronic pelvic pain and
• Classification system of parauterine venous plexus dilated myometrial vessels and pelvic veins
o Normal: Veins are small, straight, similar in caliber,
t
and easily recognized
ne
o Moderate congestion: Veins are tortuous, variable in SELECTED REFERENCES
caliber, and difficult to resolve separately 1. Nasser F et al: Safety, efficacy, and prognostic factors in
o Severe congestion: Veins are wide, markedly tortuous, endovascular treatment of pelvic congestion syndrome. Int J
e.
and vary greatly in caliber Gynaecol Obstet. 125(1):65-8, 2014
2. Durham JD et al: Pelvic Congestion Syndrome. Semin
Gross Pathologic & Surgical Features Intervent Radiol. 30(4):372-380, 2013
yn
• Primary pelvic varices are positively associated with 3. Lopera J et al: Role of interventional procedures
in obstetrics/gynecology. Radiol Clin North Am.
absent or incompetent valves and parity
o Pelvic varices and PCS can occur independently 51(6):1049-66, 2013
bg
4. Rane N et al: Pelvic congestion syndrome. Curr Probl Diagn
Radiol. 42(4):135-40, 2013
CLINICAL ISSUES 5. Ball E et al: Does pelvic venous congestion syndrome
exist and can it be treated? Acta Obstet Gynecol Scand.
ko
Presentation 91(5):525-8, 2012

• Most common signs/symptoms 6. Kies DD et al: Pelvic congestion syndrome: a review of
current diagnostic and minimally invasive treatment
o Chronic pelvic pain: May be relieved when
oo
modalities. Phlebology. 27 Suppl 1:52-7, 2012

recumbent 7. Smith PC: The outcome of treatment for pelvic congestion
▪ Dull/heavy aching pain that is associated with syndrome. Phlebology. 27 Suppl 1:74-7, 2012
movement, posture, and activities that increase 8. Freedman J et al: Pelvic congestion syndrome: the role of
eb
abdominal pressure interventional radiology in the treatment of chronic pelvic

o Dyspareunia (71%), dysmenorrhea (66%), and pain. Postgrad Med J. 86(1022):704-10, 2010
9. Asciutto G et al: Pelvic venous incompetence: reflux patterns
postcoital ache (65%)
• and treatment results. Eur J Vasc Endovasc Surg. 38(3):381-6,
://
Other signs/symptoms 2009

o Pain while walking 10. Asciutto G et al: MR venography in the detection of pelvic
o May have sharp exacerbations of pain &/or rectal venous congestion. Eur J Vasc Endovasc Surg. 36(4):491-6,
tp
discomfort &/or urinary frequency 2008

o Physical exam may show: Varicose veins (in vulva, 11. Creton D et al: Embolisation of symptomatic pelvic veins
ht
buttocks, and legs) and ovarian point tenderness in women presenting with non-saphenous varicose veins
of pelvic origin - three-year follow-up. Eur J Vasc Endovasc
upon palpation
Surg. 34(1):112-7, 2007
Demographics 12. Ganeshan A et al: Chronic pelvic pain due to pelvic
• Age congestion syndrome: the role of diagnostic and
interventional radiology. Cardiovasc Intervent Radiol.
o Most often found in multiparous women of
30(6):1105-11, 2007
reproductive age 13. Liddle AD et al: Pelvic congestion syndrome: chronic
o Pelvic varices occur in approximately 10% of female pelvic pain caused by ovarian and internal iliac varices.
population Phlebology. 22(3):100-4, 2007
▪ Up to 59% develop PCS 14. Cheong Y et al: Chronic pelvic pain: aetiology and therapy.
▪ 77% may benefit from treatment Best Pract Res Clin Obstet Gynaecol. 20(5):695-711, 2006
• Epidemiology 15. Kim HS et al: Embolotherapy for pelvic congestion
syndrome: long-term results. J Vasc Interv Radiol. 17(2 Pt
o Multiparous women of reproductive age
1):289-97, 2006
Treatment 16. Koc Z et al: Association of left renal vein variations and
• Treat with transcatheter embolization 17.

pelvic varices in abdominal MDCT. Eur Radiol. 2006
Nicholson T et al: Pelvic congestion syndrome, who should
o Sclerosing agent &/or coils we treat and how? Tech Vasc Interv Radiol. 9(1):19-23, 2006
o High rate of technical success (96-99%)
5
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PELVIC CONGESTION SYNDROME
Ovary
(Left) Coronal digital subtraction
angiography shows a complex
network tangle of myometrial
, internal iliac , and
gonadal vessels in a female
with dyspareunia and pelvic
congestion syndrome. (Right)
Delayed coronal image from
subtraction venography of the
left renal vein shows retrograde
flow and reflux of contrast down
the left ovarian vein with
collateral formation with the left
internal iliac vein .
t
ne
e.
yn
(Left) Coronal fluoroscopic spot
film in a patient undergoing
right ovarian venography for
bg pelvic congestion syndrome
shows embolization coils along
the course of the expected left
gonadal vein . Extensive
ko
engorged collaterals of the right

internal iliac venous plexus
and drainage into an enlarged
oo
right gonadal vein are seen.

(Right) Coronal CECT in a female
with pelvic congestion syndrome
shows engorged myometrial
eb
vessels and enlarged draining

left gonadal vein .
://
tp
ht
(Left) Axial CECT in a young

female with chronic pelvic pain
shows an engorged tangle of
myometrial arcuate vessels
and gonadal varices
suggestive of pelvic congestion
syndrome. (Right) Coronal CECT
in the same patient with pelvic
congestion syndrome shows the
tangle of vessels in the left
gonadal plexus and engorged
myometrial vessels .
5
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Ovary ACUTE ADNEXAL TORSION
Key Facts
Terminology o Heterogeneous, minimal, or absent enhancement
• Adnexal torsion is more accurate term than ovarian indicates evolution from ischemia to infarction
torsion, as torsion usually also includes fallopian tube Top Differential Diagnoses
Imaging • Hemorrhagic corpus luteum
• Enlarged ovary: > 4 cm in longest dimension or > 20 • Pelvic inflammatory disease
cm³ in volume • Ectopic pregnancy
• Ultrasound Pathology
o Enlarged, heterogeneously echogenic ovarian stroma
o Multiple small, peripheral, fluid-filled follicles • In adults, 50-90% have associated ovarian mass that
displaced due to edematous stroma &/or mass serves as lead point
o Whirlpool sign: Coiled, twisted pedicle o Large physiologic follicular cyst or corpus luteum
o Flow pattern depends on degree of vascular cyst most common, followed by dermoid
obstruction and chronicity of torsion • Presence of venous flow indicates viable ovary
o Venous flow affected 1st
• CT
• Presence of normal blood flow does not exclude
o Twisted pedicle most specific sign but seen in < 1/3 of
t
torsion
cases (use multiplanar reformations)
• Always look for underlying mass
ne
e.
yn
US in a young woman with
right ovary (volume: 43
bg
cm³). The central stroma
is mildly hyperechoic and
heterogeneous with peripheral
ko
displacement of small follicles
. Color Doppler showed no
flow within the ovary. These
are classic features of ovarian
oo
torsion. (Right) Pathologic

specimen in the same case
shows diffuse hemorrhagic
eb
infarction of the ovary. Note

the scattered small subcapsular
cysts , which were seen on
ultrasound.
://
tp
ht

enlarged right ovary .A
rounded fat-attenuation central
lesion represents a small
mature cystic teratoma. (Right)
Axial CECT shows an enlarged
left ovary with associated
twisted pedicle extending
from the left hemipelvis.
There is displacement of the
left ovary toward the pelvic
midline and inflammatory
change within adjacent fat .
5
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ACUTE ADNEXAL TORSION
Ovary
TERMINOLOGY CT Findings
Synonyms
• NECT
o Ovarian hematoma/hematosalpinx best seen (> 50
• Ovarian torsion HU)
o Adnexal torsion is more accurate term, as torsion
• CECT
usually also includes fallopian tube o Enlarged displaced ovary
▪ Isolated fallopian tube torsion may also rarely o Use multiplanar reformations to better see twisted
occur pedicle
Definitions ▪ Most specific sign, but only seen in < 1/3 of cases
o Deviation of uterus toward side of torsion
• Rotation of ovary on its vascular pedicle resulting in o Edematous stroma hypodense with peripherally
venous congestion and ultimately infarction of ovary
placed cysts
o Heterogeneous, minimal, or absent enhancement
IMAGING indicates evolution from ischemia to infarction
General Features MR Findings
• Best diagnostic clue • T1WI
o Enlarged echogenic ovary with prominent peripheral o Hypointense ovarian edema
follicles and absent venous flow on endovaginal color o Hyperintensity indicates hemorrhagic infarction or
t
Doppler sonography hemorrhagic cyst
ne
o Twisted vascular pedicle ▪ Look for hyperintense rim typical of subacute
• Location hematoma
o Torsed ovary/tube is often displaced from normal o Hyperintense fallopian tube/vascular pedicle
e.
location (hemorrhage)
▪ Midline, cephalad, anterior to uterine fundus, or in • T2WI
o Hyperintense small peripheral cysts with background
yn
cul-de-sac
• Size of increased ovarian signal intensity
o Enlarged ovary: > 4 cm in longest dimension or > 20 • T1WI C+
o Degree of enhancement variable depending on
cm³ in volume
bg
▪ > 10 cm³ in postmenopausal women severity of ischemia and infarction
o Volume of torsed ovary averages 28x normal o Best for twisted pedicle and evaluating for underlying
•
ko
Morphology mass
o Swollen, rounded contour
Ultrasonographic Findings • Best imaging tool
oo
o Endovaginal US with both grayscale and color

o Enlarged, heterogeneously echogenic ovarian stroma Doppler is best initial imaging examination
o Multiple small peripheral fluid-filled follicles ▪ Reported accuracy of US varies among studies
eb
displaced due to edematous stroma &/or mass (23-75%)

o Cyst may be present and is frequently thick walled o CT/MR more likely to show twisted pedicle
o Ovary is tender to touch by ultrasound probe
o Pelvic free fluid; low-level echoes indicate
://
hemoperitoneum
o Twisted vascular pedicle (broad ligament, fallopian Hemorrhagic Corpus Luteum
tp
tube, ovarian vessels)

▪ Target sign: Round hyperechoic structure, multiple
• Most common entity to be confused for torsion
• Variable appearance of cyst in otherwise normal-
ht
hypoechoic concentric stripes appearing ovary

▪ Beaked structure: Twisted fallopian tube o "Fishnet" or lace-like fibrinous strands
▪ Heterogeneous tubular structure: Edematous o Retracting clot
fallopian tube o Fluid-fluid level
• Pulsed Doppler o Diffuse low-level echoes (ground-glass appearance)
o Flow pattern depends on degree of vascular
• Increase flow around cyst on color Doppler
obstruction and chronicity of torsion
o Normal arterial and venous waveforms may be Pelvic Inflammatory Disease
present, especially in acute torsion • Uniformly thickened and dilated fallopian tubes
▪ May also be seen with incomplete (< 360° ) twist • Pyosalpinx
o Venous flow affected 1st o Contains low-level echoes or fluid-fluid level
o Due to dual arterial blood supply to ovary, arterial • ± enlarged ovaries secondary to oophoritis
flow may be preserved o Normal or increased flow pattern on color Doppler
▪ Resistive indices may be elevated
o Absent venous and arterial flow in late torsion/
• ± tubo-ovarian abscess
o Complex cystic/solid masses
ovarian infarction
• "Indefinite uterus" sign
• Color Doppler o Obscuration of posterior margin of myometrium by
o Whirlpool sign: Coiled, twisted pedicle
inflammation 5
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Obgyne Books Full
Ectopic Pregnancy o More common during pregnancy

• Positive β-hCG ▪ Usually before 20 weeks
▪ As uterus enlarges, ovaries are pushed out of pelvis
• No evidence of intrauterine pregnancy on endovaginal increasing risk of torsion
sonography
o Increased risk in women undergoing ovarian
• Extraovarian echogenic mass (clot)
• Adnexal ring separate from ovary with increased flow stimulation
o Increased risk in women with prior pelvic or
("ring of fire")
• Visualization of embryo or yolk sac within tubal abdominal surgery
gestational sac Natural History & Prognosis
• Free fluid in pelvis and Morrison pouch from • Spontaneous detorsion can recur
hemoperitoneum o Massive ovarian edema felt to result from episodes of
intermittent torsion with detorsion
PATHOLOGY ▪ Usually long history of intermittent pain
• Presence of venous flow indicates viable ovary
General Features • If no flow seen, ovary is infarcted
o In adults, 50-90% have associated ovarian mass,
usually benign • Surgical untwisting in noninfarcted adnexa either with
▪ Large physiologic follicular cyst or corpus luteum
t
laparoscopy or open surgery
o Preservation of ovary is possible if normal blood flow
ne
cyst is most common
▪ Dermoid, paraovarian cyst, and epithelial and is restored after detorsing ovary
stromal tumors can also serve as lead points for • Careful examination and removal of any mass serving
e.
torsion as lead point
o Infants and children rarely have associated mass • Salpingo-oophorectomy in infarcted ovary
▪ Hypermobility due to long mesosalpinx
yn
o Isolated tubal torsion may occur due to hydrosalpinx,
hematosalpinx, tubal neoplasms, tubal ligation,
tubal hypermotility, and hydatids of Morgagni Consider
bg
Gross Pathologic & Surgical Features • Ectopic in pregnant patient
• Torsion of both ovary and fallopian tube most Image Interpretation Pearls
• Absent venous flow in enlarged echogenic ovary with
ko
commonly found at surgery
o Isolated torsed fallopian tube possible prominent peripheral follicles is earliest reliable sign
• Ovarian torsion occurs around suspensory ligament of • Presence of normal blood flow does not exclude torsion
ovary
• Always look for underlying mass
oo
o Posterior fold of broad ligament that contains

ovarian vessels
• Twist ranges 180-720° SELECTED REFERENCES
eb
• Sequential venous, lymphatic, and arterial obstruction 1. Lourenco AP et al: Ovarian and tubal torsion: imaging
• Earliest pathologic changes include edema and findings on US, CT, and MRI. Emerg Radiol. 21(2):179-87,
2014
microscopic hemorrhage within ovary
://
o Begins centrally 2. Sasaki KJ et al: Adnexal torsion: review of the literature. J

• Prominent fluid-filled follicles displaced peripherally Minim Invasive Gynecol. 21(2):196-202, 2014
3. Duigenan S et al: Ovarian torsion: diagnostic features on CT
tp
by central edema
•
and MRI with pathologic correlation. AJR Am J Roentgenol.
Late findings include hemorrhagic infarction 198(2):W122-31, 2012
o Cystic spaces filled with blood and associated 4. Sibal M: Follicular ring sign: a simple sonographic sign
ht
hemoperitoneum for early diagnosis of ovarian torsion. J Ultrasound Med.

• Calcified mass in chronic cases 31(11):1803-9, 2012
5. Wilkinson C et al: Adnexal torsion -- a multimodality
imaging review. Clin Radiol. 67(5):476-83, 2012
CLINICAL ISSUES 6. Cicchiello LA et al: Ultrasound evaluation of gynecologic
causes of pelvic pain. Obstet Gynecol Clin North Am.
Presentation 38(1):85-114, viii, 2011
• Most common signs/symptoms 7. Mashiach R et al: Sonographic diagnosis of ovarian
o Severe unremitting acute pelvic pain is most torsion: accuracy and predictive factors. J Ultrasound Med.
30(9):1205-10, 2011
common symptom 8. Hiei K et al: Ovarian torsion; early diagnosis by MRI to
▪ Pain may be intermittent torsion/detorsion prevent irreversible damage. Clin Exp Obstet Gynecol.
o Adnexal mass may or may not be palpable 37(3):233-4, 2010
o Vomiting is common 9. Ogburn T et al: Adnexal torsion: experience at a single
o Fever if ovary is infarcted university center. J Reprod Med. 50(8):591-4, 2005
10. White M et al: Ovarian torsion: 10-year perspective. Emerg
Demographics Med Australas. 17(3):231-7, 2005
• Epidemiology 11. Gittleman AM et al: Ovarian torsion: CT findings in a child.
o 2-3% of all gynecologic emergencies J Pediatr Surg. 39(8):1270-2, 2004
5 o Most common in first 3 decades
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Obgyne Books Full
Ovary
(Left) Transvaginal US shows
an enlarged heterogeneous left
ovary posterior to the uterus
. There is an adjacent cystic
structure that proved to be
a paraovarian cyst that acted
as a lead point for the torsion.
(Right) Doppler waveforms in
the same case show reversal of
diastolic flow , indicating a
high-resistance pattern. While
abnormal flow is helpful in
making the diagnosis, it is
important to remember that a
torsed ovary may have normal
arterial and venous flow.
t
ne
e.
yn
(Left) Color Doppler in a patient
with severe right lower quadrant
pain shows an enlarged (6 cm
bg in length) rounded ovary with
peripheral follicles . Blood
flow is seen , and despite
normal Doppler waveforms (not
ko
shown), torsion was suspected

and confirmed at surgery. (Right)
Axial T2WI MR in a pregnant
oo
woman with pelvic pain shows

a massively enlarged right ovary
containing a large cyst
(normal left ovary , cervix
eb
). Pregnancy is a risk factor for

ovarian torsion.
://
tp
ht
(Left) CECT in a woman with

right ovary displaced into the cul-
de-sac. There is both fat and
calcification present, as well
as adjacent soft tissue stranding
. The patient was taken to
surgery for a presumed torsion of
an ovarian dermoid. (Right) An
intraoperative photograph shows
the twisted pedicle and
infarcted ovary . Pathology
confirmed the presence of a
dermoid. Remember that most
cases of ovarian torsion have a
mass serving as the lead point.
5
239
Obgyne Books Full
(Left) Axial T2WI MR in an 11-

with acute right pelvic pain
shows an enlarged right ovary
showing diffuse increase
in signal intensity making it
difficult to differentiate from
surrounding fat. The left ovary
is normal in size. (Right)
Sagittal T2 STIR in the same
right ovary showing diffuse
homogeneous increase in
signal intensity. Visualization
of the ovary is better due to fat
suppression.
t
ne
e.
yn
bg
signal intensity that is similar
to or slightly higher than the
pelvic skeletal muscle. The
ko
left ovary is normal in size.

oo
the enlarged nonenhancing

right ovary and normally
enhancing left ovary .
Laparoscopy revealed torsion
eb
of the right ovary, which was

successfully detorsed.
://
tp
ht

acute pelvic pain shows
an enlarged ovary with
heterogeneous edematous
stroma and multiple small
peripheral follicles . (Right)
Axial transvaginal Doppler
shows definite arterial flow
within the enlarged ovary.
Dual blood supply via the
ovarian and uterine arteries
may allow preservation of
blood flow despite torsion.
Arterial flow may be seen in up
to 25% of torsion cases.
5
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Obgyne Books Full
Ovary
year-old pregnant woman
who presented with left pelvic
pain shows an enlarged left
ovary containing 2 cystic
structures . The left ovary
is displaced anterior to the
gravid uterus. Torsed ovaries
are often displaced from their
normal location. (Right) Coronal
shows the enlarged left ovary
containing 2 simple-appearing
cystic structures .
t
ne
e.
yn
(Left) Axial CECT shows a large,
simple-appearing cystic mass
in the left hemiabdomen. (Right)
bg Coronal CECT shows a large
cystic mass with associated
twisted pedicle extending
from the left hemipelvis. A
ko
twisted pedicle is the most

specific finding of torsion but is
seen in < 1/3 of cases. In adults,
oo
50-90% have associated ovarian

mass, usually benign, most likely
a physiologic cyst.
eb
://
tp
ht

with severe acute pelvic pain
shows multiple fluid-filled cystic
appearing structures (Right)
patient shows fluid-filled dilated
tubular structures . The 2 ends
of the structure approach each
other in a twisted configuration
. Laparoscopy revealed
isolated left tubal torsion. The left
ovary was completely normal.
5
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Obgyne Books Full
Ovary MASSIVE OVARIAN EDEMA AND FIBROMATOSIS
Key Facts
• Massive ovarian edema (MOE): Tumor-like ovarian • Ovarian torsion
enlargement secondary to edema • Solid ovarian neoplasm
• Ovarian fibromatosis (OF): Tumor-like ovarian • Hemorrhagic cyst
enlargement due to fibromatous growth of ovarian
stroma
• Edematous fibroma
Clinical Issues
Imaging
• Both conditions are usually unilateral • Rare
• Diffuse ovarian enlargement with maintained ovarian • Recurrent intermittent abdominal pain or distension
configuration • Palpable pelvic mass
o MOE: Enlarged ovary with edematous appearance • Luteinization and stromal hyperplasia result in ↑ in
and peripheral follicles ovarian androgen and estrogen production
o OF: Enlarged ovary with segmental or peripheral • Mean age at diagnosis of 20 years
areas of T1 and T2 low signal intensity • Conservative management with detorsion and frozen
• OF: “Black garland” appearance has been reported section to exclude tumor is current treatment of choice
on T2WI, which is caused by fibrous tissue encasing
t
peripheral aspect of ovary
ne
e.
yn
shows ovarian enlargement
with multiple small,
bg
peripheral cysts . Both
arterial and venous flow are
seen within the enlarged ovary.
ko
It is important to recognize
this pattern and suggest the
diagnosis preoperatively so
more conservative surgery can
oo
be performed. (Right) Axial

transabdominal color Doppler
eb
girl shows an enlarged ovary

with minimal flow at the
periphery. There is no definite
flow in the central portions of
://
the lesion.
tp
ht

year-old woman shows
an enlarged left ovary .
The enlarged ovary shows
diffuse low attenuation due
to stromal edema, with
numerous peripherally located
ovarian follicles . Note
the normal right ovary
containing multiple follicles.
(Right) Coronal T2WI MR
in a 16-year-old girl shows
an enlarged hyperintense
ovary containing multiple
peripherally located round
follicles . Note also the
areas of low signal intensity
due to fibromatosis.
5
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MASSIVE OVARIAN EDEMA AND FIBROMATOSIS
Ovary
TERMINOLOGY ▪ High signal intensity of ovarian stroma
– Signal intensity on T2WI increases with heavier
Abbreviations T2 weighting
• Massive ovarian edema (MOE) ▪ Distinguished from tumor by presence of
• Ovarian fibromatosis (OF) o OF
peripheral follicles
Definitions ▪ Low T2 signal areas that correspond to fibrous

• Massive ovarian edema: Tumor-like ovarian tissue
enlargement secondary to edema ▪ “Black garland” appearance has been reported on
• Ovarian fibromatosis: Tumor-like ovarian enlargement T2WI, which is caused by fibrous tissue encasing
due to fibromatous growth of ovarian stroma peripheral aspect of ovary
• It appears that both conditions are related to partial or • T1WI C+ FS
intermittent torsion, leading to venous and lymphatic o MOE
obstruction with subsequent ovarian enlargement ▪ May or may not show enhancement centrally
o Chronic torsion may primarily lead to fibromatosis – Central enhancement is stronger than
or massive edema (not clear which is 1st) enhancement in remainder of ovary
o OF
IMAGING ▪ Little or no parenchymal (venous) phase
enhancement; delayed enhancement may be seen
t
General Features
ne
o MOE
o MOE
▪ Enlarged ovary with edematous appearance and
▪ Enlarged ovary
e.
peripheral follicles
o OF ▪ Echogenic stroma and peripherally displaced
▪ Enlarged ovary with segmental or peripheral areas follicles
yn
▪ Well-defined capsule
of T1 and T2 low signal intensity
▪ Focal tenderness while scanning
• Location
o OF
o Both conditions are usually unilateral
bg
▪ Enlarged heterogeneously echogenic ovary with
▪ Right: 75%
areas of acoustic shadowing due to presence of
– Predisposition of right ovary may be due to
fibrous tissue
•
ko
elevated right ovarian vein pressure relative to
Color Doppler
left, reducing tolerance of right ovary to partial
o Doppler flow is typically present in both conditions,
torsion
o Bilateral: 15% usually low flow
oo
▪ Presence of blood flow does not exclude this

• Size
diagnosis
o MOE
o Venous waveforms may be difficult to obtain
▪ Range: 5.5-15 cm (mean: 10 cm)
eb
o OF
▪ Range: 6-12 cm (mean: 8 cm) DIFFERENTIAL DIAGNOSIS
• Morphology
Ovarian Torsion
://
o Diffuse ovarian enlargement with maintained

ovarian configuration • Enlarged ovary with ipsilateral pain
o Ovary may have teardrop configuration • Lack of flow in some cases; however, flow may be
tp
▪ Supports concept that MOE reflects chronic present in cases of incomplete or partial torsion
vascular congestion of ovary, with ovarian pedicle • In setting of ovarian infarction, torsed ovary appears
ht
being either torsed or compressed heterogeneous
CT Findings
• Since MOE and OF are caused by chronic or
intermittent torsion, recognizing their imaging features
• MOE is important to alert surgeon that ovary is salvageable
o Enlarged ovary of low attenuation and peripherally and that ovarian enlargement is not result of tumor
located rounded follicles
• OF
Solid Ovarian Neoplasm
• Solid lesion
o Nonspecific heterogeneous ovarian enlargement
with little parenchymal (venous) phase • Lack of peripheral follicles
enhancement Hemorrhagic Cyst
MR Findings • Lack of internal flow
• T1WI • Retractile clot
o Low signal intensity of ovarian stroma
Edematous Fibroma
o Focal or segmental areas of increased T1 signal
intensity (possibly reflecting hemorrhage)
• Lacks follicles within ovarian stroma
• T2WI
o MOE
5
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General Features
• Frequently surgically removed, even though benign,
due to overlap in appearance with solid ovarian lesion
• Etiology • Conservative management with detorsion and frozen
o Intermittent torsion, with partial venous and section to exclude tumor is current treatment of choice
lymphatic obstruction
o May be associated with benign ovarian neoplasms
• May cause precocious puberty
o Precocious puberty can be reversed after surgical
(e.g., cystadenoma) or ovulation induction detorsion
o Rarely, secondary to lymphatic permeation by
metastatic carcinoma Treatment
• Check histology on frozen section to exclude
malignancy
• MOE: Soft, with watery cut surface • Wedge resection to debulk ovary
o Unlike complete/acute torsion, MOE is typically not
• Detorsion (torsion present in 1/2 of cases)
associated with infarction or necrosis as venous and
lymphatic flow are compromised and arterial flow
• Bilateral gonadopexy to prevent both ipsilateral
recurrence and contralateral occurrence
remains preserved
o Ovary remains viable
• OF: Lobulated surface and firm, white, solid > cystic on DIAGNOSTIC CHECKLIST
t
cut section
Consider
ne
Microscopic Features • Consider massive ovarian edema when enlarged
• MOE edematous-appearing ovary is seen in young woman
o Extensive stromal edema separating normal ovarian • Intraoperative biopsy is diagnostic and can lead to
e.
structures (follicles, corpora albicantia, etc.) but ovary-sparing surgery
typically sparing cortex, imparting hypocellular Image Interpretation Pearls
yn
appearance
o Microcystic appearance secondary to edema • Enlarged edematous-appearing ovary with peripheral
follicles should suggest this diagnosis
o Variable amounts of recent hemorrhage
• Presence of blood flow does not exclude diagnosis of
o Dilated hilar vessels
bg
MOE
o Capsule with dense collagen tissue spared from
edematous changes
•
ko
OF SELECTED REFERENCES
o Variably cellular, spindled stroma embedded in dense 1. Beurdeley M et al: Ovarian fibromatosis and sotos syndrome
collagen entrapping preexisting normal structures with a new genetic mutation. J Pediatr Adolesc Gynecol.
o Predominantly fascicular with minor storiform
oo
26(2):e39-41, 2013
pattern 2. George V et al: Chronic fibrosing conditions in abdominal
o May be focal and only involve ovarian cortex imaging. Radiographics. 33(4):1053-80, 2013
o Minor sex cord-like elements rare 3. Guzel AB et al: Unusual adnexal masses in adolescents and
eb
young women: massive ovarian oedema. J Obstet Gynaecol.

o Clusters of luteinized stromal cells (40%)
33(6):635-6, 2013
4. Praveen R et al: A clinical update on massive ovarian oedema
- a pseudotumour? Ecancermedicalscience. 7:318, 2013
://
CLINICAL ISSUES 5. Coakley FV et al: Magnetic resonance imaging of massive

Presentation ovarian edema in pregnancy. J Comput Assist Tomogr.

tp
34(6):865-7, 2010
6. Diamantopoulou S et al: Serous cystadenoma with massive
o Recurrent intermittent abdominal pain or distension ovarian edema. A case report and review of the literature.
o Palpable pelvic mass
ht
Clin Exp Obstet Gynecol. 36(1):58-61, 2009

• Other signs/symptoms 7. Telischak NA et al: MRI of adnexal masses in pregnancy. AJR
o Luteinization and stromal hyperplasia result in ↑ in Am J Roentgenol. 191(2):364-70, 2008
ovarian androgen and estrogen production 8. Natarajan A et al: Precocious puberty secondary to massive
▪ Hyperandrogenism may result in amenorrhea, ovarian oedema in a 6-month-old girl. Eur J Endocrinol.
150(2):119-23, 2004
menorrhagia, metrorrhagia, hirsutism, virilization 9. Spurrell EL et al: A case of ovarian fibromatosis and
▪ May present as precocious puberty, reported in case massive ovarian oedema associated with intra-abdominal
as young as 6 months of age fibromatosis, sclerosing peritonitis and Meig's syndrome.
o May occasionally complicate pregnancy Sarcoma. 8(4):113-21, 2004
10. Umesaki N et al: Successful preoperative diagnosis of
Demographics massive ovarian edema aided by comparative imaging study
• Age using magnetic resonance and ultrasound. Eur J Obstet
o May occur at any age, with mean age at diagnosis of Gynecol Reprod Biol. 89(1):97-9, 2000
20 years 11. Roberts CL et al: Bilateral massive ovarian edema: a case
• Epidemiology
12.
report. Ultrasound Obstet Gynecol. 11(1):65-7, 1998
Kramer LA et al: Massive edema of the ovary: high resolution
o Both conditions are rare
MR findings using a phased-array pelvic coil. J Magn Reson
Imaging. 7(4):758-60, 1997
5 13. Hall BP et al: Massive ovarian edema: ultrasound and MR

characteristics. J Comput Assist Tomogr. 17(3):477-9, 1993
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Ovary
year-old girl who presented with
intermittent pelvic pain and a
recent episode of acute pain
shows an enlarged left ovary
with marked increased signal
intensity and peripherally located
follicles . There is a simple-
appearing elongated left adnexal
structure separate from the
ovary. (Right) Sagittal T2WI MR
enlarged hyperintense left ovary
. The ovarian hilum is seen
as a central slightly hypointense
structure.
t
ne
e.
yn
same patient shows the enlarged
left ovary demonstrating
bg homogeneous low signal
intensity. The left adnexal cystic
structure shows fluid signal
intensity lower than that of the
ko
ovary. (Right) Axial T1WI FS

the enlarged left ovary
oo
low signal intensity that is
comparable to that of pelvic
skeletal muscles and higher than
eb
the signal intensity of the fluid-

filled left adnexal cystic structure
.
://
tp
ht

the enlarged left ovary and
the left adnexal cystic lesion
. (Right) Sagittal T1WI C+ FS
the enlarged left ovary and
the left adnexal cystic lesion
. During surgery, the left
adnexal mass was found to be a
paraovarian simple cyst. Wedge
resection of the ovary showed
massive ovarian edema. The
ovary was torsed and regained
normal color after detorsion.
5
245
Obgyne Books Full

with acute pelvic pain shows
with marked increased signal
intensity. There is a segmental
area of low signal intensity
due to fibromatosis and
multiple peripherally displaced
ovarian follicles . (Right)
hyperintense right ovary
containing multiple rounded
follicles . The normal-
appearing left ovary
t
containing normal follicles is
ne
seen.
e.
yn
enlarged right ovary
bg
low signal intensity. There
is a segmental area of lower
signal intensity due to
ko
fibromatosis. (Right) Axial

T1WI FS MR in the same
oo
right ovary demonstrating

intensity with a segmental
area of lower signal intensity
eb
and multiple peripherally

displaced ovarian follicles .
://
tp
ht

the enlarged right ovary .
absence of enhancement
of the enlarged right ovary
and enhancement of
the normal left ovary
containing multiple small
follicles. During surgery,
wedge resection revealed
massive ovarian edema. The
ovary was torsed and regained
normal color after detorsion.
5
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Ovary
woman who presented with a
long history of intermittent pelvic
pain shows an enlarged diffusely
hypoattenuating left ovary
. Only the area of ovarian
hilum shows enhancement.
same patient shows an enlarged
diffusely hypoattenuating left
ovarian enlargement due
to diffuse stromal edema, with
enhancement of the ovarian
hilum .
t
ne
e.
yn
(Left) Axial T2WI MR shows an
enlarged edematous ovary with
peripheral round follicles .
bg (Right) Transverse T1WI MR
(same patient) shows low signal
intensity of the enlarged ovary
with a well-defined capsule and
ko
peripheral hyperintense follicles

. Massive ovarian edema
may be mistaken for a solid
oo
ovarian neoplasm. However, the

presence of peripheral follicles
helps to differentiate massive
ovarian edema from ovarian
eb
neoplasm.
://
tp
ht

MR shows bilateral ovarian
enlargement with homogeneous
peripheral low signal intensity
, resulting in the “black
garland” appearance that has
been described with ovarian
fibromatosis, which is caused
by fibrous tissue encasing the
peripheral aspect of the ovary.
(Right) Axial T1 C+ FS MR in
the same patient shows mild
enhancement of enlarged ovaries
, right greater than left, on
delayed imaging.
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ne
e.
yn
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oo
eb
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SECTION 6
Fallopian Tubes
Congenital
t
ne
Paratubal Cyst 6-2
e.
Pelvic Inflammatory Disease, General Considerations 6-6
yn
Hydrosalpinx 6-10
Pyosalpinx 6-14
Tubo-Ovarian Abscess 6-18
bg
Genital Tuberculosis 6-22
Actinomycosis 6-26
ko
Salpingitis Isthmica Nodosa 6-30
Benign Neoplasms
oo
Tubal Leiomyoma 6-34
Malignant Neoplasms
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Fallopian Tube Carcinoma 6-38
Miscellaneous
://
Hematosalpinx 6-54
tp
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Fallopian Tubes PARATUBAL CYST
Key Facts
• Simple unilocular adnexal cyst separate from ovary • Ovarian cysts
• Variable size; average: 8 cm • Peritoneal inclusion cysts
• Thin smooth wall • Lymphocele
• Unilateral • Hydrosalpinx
• Usually single, but can be multiple • Ectopic tubal pregnancy
• CT: Fluid attenuation mass, no enhancement Pathology
• MR: ↓ T1, ↑ T2, no enhancement • Usually arise from peritoneal mesothelium of broad
• US: Anechoic, unilocular, thin smooth wall
• Separate ovary retains normal ovoid shape
ligament
• Ovary may be separated from cyst with transvaginal Clinical Issues

transducer pressure • Asymptomatic and discovered incidentally
• Complications • Symptomatic if large (> 5 cm) or if undergo torsion
o Focal wall thickening or internal hemorrhage may • Complications: Hemorrhage, rupture, infection,
indicate torsion torsion
o Solid component may indicate benign or malignant • Malignancy in 2-3%, usually cystic mass > 5 cm
t
• No treatment or follow-up necessary for vast majority
ne
transformation
e.
yn
(Left) Sagittal T2WI FSE MR in
a patient with a fimbrial cyst
shows an intermediate signal
linear structure extending
bg
toward an oval, circumscribed,
hyperintense mass . (Right)
ko
same patient shows a normal
ipsilateral ovary containing
small follicles and separate
from the cystic mass.
oo
eb
://
tp
ht

hypointensity, and absence
of enhancement within the
mass confirms a simple
cyst separate from the ovary
and located at the fimbrial
end of the fallopian tube .
(Right) Axial CECT shows an
oval fluid-density mass
separate from the ovary
and located at the fimbrial
end of the fallopian tube ,
compatible with a fimbrial
cyst.
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PARATUBAL CYST
Fallopian Tubes
TERMINOLOGY ▪ No mural nodules or solid components
▪ Thin, imperceptible wall
Synonyms ▪ Increased through transmission
• Paraovarian cyst o In close proximity but separate from ipsilateral ovary
• Fimbrial cyst ▪ Ovary retains normal ovoid shape
▪ Ovary may be separated from cyst with
• Hydatid cyst of Morgagni transvaginal transducer pressure
Definitions o Internal hemorrhage or torsion
• Simple epithelial lined adnexal cyst separate from ovary ▪ Focal cyst wall thickening, typically portion of wall
• Cystic dilation of longest fimbria of fallopian tube in contact with fallopian tube or mesosalpinx
▪ Echogenic internal debris or clot
o Transformation to benign or malignant tumor
IMAGING ▪ Multiple small mural nodules
▪ Larger papillary projections
General Features
▪ Septations
o Simple unilocular adnexal cyst separate from nearby Imaging Recommendations
ovary
o Focal wall thickening or internal hemorrhage may
o Transvaginal ultrasound
o MR may be helpful if cyst is complex or cannot be
t
indicate torsion
o Solid component may be benign or indicate
ne
separated from ovary on TVUS
malignant transformation • Protocol advice
• Size o Ovary can sometimes be separated from paraovarian
o Variable size; average 8 cm
e.
cyst by gentle pressure on transvaginal transducer
▪ Reported up to 18 cm o Subtraction images (postcontrast minus precontrast)
• Morphology are helpful to exclude solid component if cyst is
yn
o Thin, smooth wall hemorrhagic (has intrinsic T1 signal)
o Usually single, but can be multiple
o Unilateral
bg DIFFERENTIAL DIAGNOSIS
▪ Rare bilateral cysts
o Unilocular Ovarian Cysts
▪ Septated or multiloculated cysts are uncommon
• "Claw" sign: Crescentic ovarian tissue around cyst
ko
CT Findings • Moves with ovary with transvaginal transducer

• CECT pressure
o Fluid attenuation mass separate from ovary • Physiologic ovarian cysts will resolve on follow-up
oo
o No contrast enhancement ultrasound
MR Findings Peritoneal Inclusion Cysts

• T1WI • Ovary is part of lesion either within cyst or within cyst
eb
o Low signal intensity wall

o High signal intensity suggests hemorrhage into cyst • Requires presence of hormonally active ovary
producing fluid and peritoneal adhesions
://
&/or torsion o Fluid entrapped by adhesions

• T2WI
• Associated with a history of prior surgery, trauma,
o Homogeneous high signal intensity in simple cyst
tp
o Heterogeneity in cyst fluid suggests hemorrhage due endometriosis, pelvic inflammatory disease
to torsion Lymphocele
• Expansion of lymphatic channels in pelvic sidewall
ht
o Can be multicystic and have mural nodules or

septations • Located in pelvic sidewall rather than in adnexal region
o Helpful sequence for identification of separate ovary
• Nonmobile
• T1WI C+
• Associated with prior surgery on lymphatic chains,
o No enhancement in simple cyst most commonly lymphadenectomy
o Focal wall thickening may be seen with internal
hemorrhage or torsion Hydrosalpinx
o Enhancing mural nodules or septations may indicate • Tubular configuration
benign or malignant transformation • Contains folds, incomplete septa
o Use subtraction images to find enhancing solid
components in background of hemorrhagic contents Ectopic Tubal Pregnancy
▪ Postcontrast minus precontrast • Positive pregnancy test, pain, vaginal bleeding
• Not anechoic
• May see complex free fluid
o Simple adnexal cyst
▪ Anechoic
▪ Unilocular but uncommonly can be multicystic
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Fallopian Tubes PARATUBAL CYST
PATHOLOGY ▪ May be simple cyst or appear simple due to

inability to resolve small nodules and thin
General Features septations
• Etiology o Cystadenofibromas
o Low malignant potential or borderline tumors with
o 10-20% of adnexal masses
o Peak incidence: 3rd-4th decades various degrees of epithelial proliferation
▪ Median age: 31 ▪ Endometrioid cystadenocarcinoma
o Rare in children or adolescents ▪ Serous cystadenocarcinoma
o Classically believed to be hormone-insensitive ▪ Mucinous cystadenocarcinoma
inclusion cysts; however, growth reported in Treatment
pregnant patients
o Usually arise from peritoneal mesothelium of broad • No treatment or follow-up necessary for vast majority
• If symptomatic, may be removed laparoscopically
• Removed if complex cyst due to risk of malignant
ligament
o Less commonly derived from mesonephric (wolffian)
transformation
• If malignancy is suspected, rupture of lesion should be
or paramesonephric (müllerian) structures
▪ Paramesonephric duct remnants develop due to
avoided to prevent peritoneal tumor dissemination
• Value of ultrasound-guided fine-needle aspiration is
cystic dilation of largest fimbria of fallopian tube
Gross Pathologic & Surgical Features not clear
• Simple unilocular cyst filled with clear serous fluid
t
ne
• May cause torsion because arise on a thin pedicle DIAGNOSTIC CHECKLIST
attached to fallopian tube, broad ligament, or ovary
• Lining of cyst is smooth Image Interpretation Pearls
• Unilocular adnexal cyst separate from ovary
e.
• Lined by single layer of cuboidal or columnar • Papillary projections and septations should raise
yn
concern for benign, borderline, or malignant tumor
epithelium
• Lined by ciliated and nonciliated cells
• Atrophy and compression may lead to flattening of SELECTED REFERENCES
bg
epithelium causing nonspecific appearance 1. Terek MC et al: Paratubal borderline tumor diagnosed in the
adolescent period: a case report and review of the literature.
J Pediatr Adolesc Gynecol. 24(5):e115-6, 2011
CLINICAL ISSUES
ko
2. Moyle PL et al: Nonovarian cystic lesions of the pelvis.
Presentation Radiographics. 30(4):921-38, 2010
• Most common signs/symptoms 3. Breitowicz B et al: Torsion of bilateral paramesonephric cysts

in young girls. Acta Obstet Gynecol Scand. 84(2):199-200,
oo
o Asymptomatic and discovered incidentally 2005

o Symptomatic if large (> 5 cm) or if undergo torsion 4. Low SC et al: Paratubal cyst complicated by tubo-ovarian
▪ Pain torsion: computed tomography features. Australas Radiol.
▪ Increased abdominal girth
eb
49(2):136-9, 2005
▪ Irregular menstruation 5. Salamon C et al: Borderline endometrioid tumor arising in
▪ Anorexia, nausea/vomiting a paratubal cyst: a case report. Gynecol Oncol. 97(1):263-5,
• 2005
://
Other signs/symptoms 6. Fujii T et al: Parovarian cystadenoma: sonographic features

o Postulated as a cause of infertility associated with magnetic resonance and histopathologic
▪ Cyst interferes with egg transfer from adjacent findings. J Clin Ultrasound. 32(3):149-53, 2004
tp
ovary 7. Kishimoto K et al: Paraovarian cyst: MR imaging features.

Abdom Imaging. 27(6):685-9, 2002
ht
8. Korbin CD et al: Paraovarian cystadenomas and

• Almost always benign; no follow-up required cystadenofibromas: sonographic characteristics in 14 cases.
• Complications Radiology. 208(2):459-62, 1998
o Hemorrhage 9. Barloon TJ et al: Paraovarian and paratubal cysts:
preoperative diagnosis using transabdominal and
o Rupture
transvaginal sonography. J Clin Ultrasound. 24(3):117-22,
o Infection 1996
o Torsion in 2-16% 10. Kim JS et al: Sonographic diagnosis of paraovarian cysts:
• Rare benign and malignant neoplastic transformation value of detecting a separate ipsilateral ovary. AJR Am J
o Mural nodules may be present in benign and Roentgenol. 164(6):1441-4, 1995
malignant neoplasms 11. Athey PA et al: Sonographic features of parovarian cysts. AJR
▪ Epithelial papillary proliferation or fibrotic Am J Roentgenol. 144(1):83-6, 1985
12. Samaha M et al: Paratubal cysts: frequency, histogenesis, and
nodules covered with a single layer of epithelium associated clinical features. Obstet Gynecol. 65(5):691-4,
o Most benign, incidence of malignancy 2-3% 1985
▪ Incidence even less if cyst is < 5 cm in size 13. Alpern MB et al: Sonographic features of parovarian
o Papillary serous cystadenoma cysts and their complications. AJR Am J Roentgenol.
▪ May be associated with von Hippel-Lindau disease 143(1):157-60, 1984
▪ Often has small nodular projections from wall, less
6 commonly has septations
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PARATUBAL CYST
Fallopian Tubes
(Left) Transabdominal US shows
an anechoic mass with
imperceptible wall and posterior
acoustic enhancement. This is
separate from the ovary and
consistent with a paraovarian
cyst. Transabdominal US is
helpful for visualization and
localization of large adnexal
masses. It is also useful for
differentiating a large simple cyst
from the urinary bladder .
(Right) Transvaginal ultrasound
shows a simple cyst clearly
separate from the ovary
compatible with a paraovarian
t
cyst .
ne
e.
yn
in a patient with bilateral
fimbrial cysts shows a small,
bg oval, hyperintense mass at
the ampullary end of the
right fallopian tube . Note
normal and separate right ovary
ko
. (Right) Sagittal T2WI FSE

preservation of normal shape
oo
and contour of the left ovary

with an adjacent round,
hyperintense mass consistent
with the fimbrial cyst.
eb
://
tp
ht

the same patient again shows the
normal ovaries are separate
with preservation of the normal
oval shape and smooth external
contour. (Right) Axial T1WI C+
FS MR in the same patient shows
hypointensity and absence of
enhancement of the adnexal
masses confirming simple
cysts. They are located at the
ampullary end of each fallopian
tube compatible with fimbrial
cysts.
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Fallopian Tubes PELVIC INFLAMMATORY DISEASE, GENERAL CONSIDERATIONS
Key Facts
• Infection of upper female genital tract • Perforated appendicitis
Imaging • Ovarian torsion
• PID is most often clinical diagnosis • Ruptured dermoid
• Primary goal of imaging is to evaluate for Pathology
complications and potential treatment planning • Sexually transmitted disease most commonly caused
• Imaging may be normal in early or uncomplicated PID by Neisseria gonorrhoeae or Chlamydia trachomatis
• Pyosalpinx: Echogenic debris within fallopian tube o 30-40% are polymicrobial
o "Cogwheel" sign: Thickened longitudinal folds
Clinical Issues
• Common symptoms include vaginal discharge, pelvic
of fallopian tube have nodular appearance when
viewed in cross section
• Tubo-ovarian/pelvic abscesses pain, fever, and increased white blood cell count
• Long-term sequelae
• Inflammatory changes in surrounding fat with
o 10-15% of women may become infertile
obscuration of soft tissue planes
o Increased risk of ectopic pregnancy
• Fitz-Hugh-Curtis syndrome: Inflammation of right
• Antibiotic therapy for uncomplicated PID
t
upper quadrant (RUQ) peritoneal surfaces from
• Percutaneous or open drainage of abscesses
ne
infection extending up paracolic gutter
e.
yn
a typical case of bilateral
tubo-ovarian abscesses. The
fallopian tubes are markedly
bg
thickened and filled with
fluid. (Right) Lower in the
pelvis are complex thick-walled
ko
fluid collections , which
are abscesses presumably
involving the ovaries. In
severe infections like this,
oo
the fallopian tube and ovary

cannot be identified as distinct
structures and form a tubo-
eb
ovarian complex. Note the

uterus . There is free fluid
in the pelvis extending into the
cul-de-sac .
://
tp
ht
(Left) Transvaginal US
shows pyosalpinx filled
with echogenic debris .
The dilated fallopian tube
has a nodular "cogwheel"
appearance due to
thickening of the longitudinal
folds. The ovary is not
involved in this case. (Right)
To prove unequivocally that it
is a dilated tube, it is important
to scan in oblique planes to
elongate it. In this case of the
same patient, there is a fluid-
debris level , another typical
finding of a pyosalpinx, and an
incomplete septum created
by the fallopian tube folding
6 back on itself.
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PELVIC INFLAMMATORY DISEASE, GENERAL CONSIDERATIONS
Fallopian Tubes
o Abnormal endometrial/endocervical enhancement
TERMINOLOGY
with fluid in cavity
Abbreviations o Enhanced peritoneum on CECT
• Pelvic inflammatory disease (PID) o Free fluid in pelvis
Definitions
• Advanced PID
o Pyosalpinx
• Infection of upper female genital tract including ▪ Greater degree of wall thickening, enhancement
endometrium, fallopian tubes, ovaries, and peritoneal ▪ Filled with complex fluid, fluid-debris level
cavity o Tubo-ovarian or pelvic abscess
o Includes endometritis, salpingitis, pyosalpinx,
▪ Complex fluid collection ± internal septa
oophoritis, tubo-ovarian abscesses (TOA), pelvic – Always look in cul-de-sac in addition to adnexa
abscesses ▪ Thick walled with ill-defined outer borders
▪ Inner borders may be irregular
IMAGING ▪ More marked inflammatory changes in
surrounding fat with obscuration of soft tissue
General Features planes
• Best diagnostic clue o Involvement of adjacent structures
o Dilated fallopian tube with low-level echoes ▪ Thickening of small/large bowel wall, bladder wall
(pyosalpinx) ▪ Small or large bowel ileus/obstruction
t
• Most often a clinical diagnosis ▪ Ureteropelviectasis from functional or mechanical
ne
• Primary goal of imaging is to evaluate for obstruction
▪ Thrombophlebitis of pelvic vessels
complications and potential treatment planning
– May cause ovarian vein thrombosis
e.
Ultrasonographic Findings ▪ Fitz-Hugh-Curtis syndrome
• Early PID – Inflammation of right upper quadrant (RUQ)
o May be normal
yn
peritoneal surfaces from infection extending up
o May be painful when probe touches cervix paracolic gutter
▪ Ultrasound equivalent of cervical motion – Hepatic capsular enhancement on late arterial
tenderness on clinical exam
bg phase shown to be specific finding of PID
o Fallopian tube thickening ± distention – Causes perihepatitis with periportal and
o Enlarged ovaries with indistinct margins ± cysts subcapsular perfusional abnormalities
▪ Normal to increased flow on color Doppler – Gallbladder wall thickening
ko
o "Indefinite" uterus sign

▪ Inflammation and echogenic fluid in the cul- MR Findings
de-sac obscure uterine margins, especially along • T1WI
o Fluid has variable appearance according to protein
oo
posterior border (also seen on CT)

o Increased echogenicity of pelvic fat content
• Advanced PID ▪ Hypointense to intermediate signal intensity
o Abscess cavity may have hyperintense rim from
o Pyosalpinx
eb
▪ Echogenic debris within fallopian tube granulation tissue

– May see fluid-debris level • T2WI
▪ Fallopian tube wall thickening with increased o High signal intensity fluid with low signal intensity
://
echogenicity septa
– May see increased flow in wall on color Doppler • T1WI C+
tp
▪ "Cogwheel" sign o Enhancement of thickened fallopian tubes and

– Thickened longitudinal folds of fallopian tube surrounding inflammatory tissue
ht
have nodular appearance when viewed in cross

section
▪ Incomplete septa
o US for initial evaluation and follow-up, guidance for
– Created by fallopian tube folding back on itself
o Tubo-ovarian/pelvic abscess abscess/pyosalpinx drainage
o CT for complicated PID
▪ Fallopian and ovary can no longer be identified as
separate structures; form tubo-ovarian complex ▪ Late arterial phase shown to be most sensitive for
▪ Multilocular/unilocular, complex, thick-walled, making diagnosis
o MR most useful in setting of chronic PID
cystic adnexal mass
▪ Helps differentiate hydrosalpinx vs. peritoneal
CT Findings inclusion cysts from adhesions vs. cystic ovarian
• Early PID masses
o May be normal
o Mild pelvic edema
▪ Haziness/stranding of pelvic fat, obscuring of
fascial planes Perforated Appendicitis
o Mild salpingitis: Mural thickening of fallopian tube
o Mild oophoritis: Enlarged, heterogeneously
• Dilated appendix > 6 mm ± appendicolith
enhancing ovaries ± polycystic appearance of ovaries
• Cecum and terminal ileum may be thickened 6
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Fallopian Tubes PELVIC INFLAMMATORY DISEASE, GENERAL CONSIDERATIONS
• Soft tissue stranding in mesoappendix and ▪ Cervix in teenage girls not fully matured,
periappendiceal fat increasing risk of ascending infection
• May form right lower quadrant abscess • Epidemiology
o Affects > 750,000 women annually in United States
Ovarian Torsion
• Enlarged heterogeneous ovary with prominent Natural History & Prognosis
peripheral follicles • Most respond to therapy
• "Whirlpool" sign: Twisted vascular pedicle • Rupture of TOA can cause life-threatening peritonitis
• Normal to diminished vascularity of adnexa • Potential long-term sequelae
o 10-15% of women may become infertile
Ruptured Dermoid
▪ Tubal occlusion and hydrosalpinx formation
• Cystic mass containing fat &/or calcifications o Increased risk of ectopic pregnancies
• Extruded contents cause chemical peritonitis ▪ Salpingitis can result in salpingitis isthmica
o Soft tissue inflammatory changes in pelvis
nodosum
• Ectopic location suggests torsion, a predisposing factor o Bowel obstruction due to adhesions
for rupture
Treatment
Diverticulitis
• Antibiotic therapy for uncomplicated PID
• Usually left-sided involving sigmoid colon • Percutaneous drainage of abscesses
• Thickened colon wall
t
o Transvaginal drainage often best approach for pelvic
• Usually obvious diverticulosis
ne
collections
• May seen bubbles of gas from perforated diverticula ▪ Higher rate of catheter dislodgment than
• May be complicated by abscess formation transabdominal
• Generally older age group than typical PID patient o Other approaches include transabdominal,
e.
transgluteal, or transrectal depending on location of
abscess
yn
PATHOLOGY o Catheter removal criteria
General Features ▪ Resolution of fever and leucocytosis
▪ Drainage output < 10-20 mL/day
• Etiology
bg
o Ascending infection from vagina, which progresses ▪ No fistula or large cavity on catheter injection
to involve cervix, uterus, fallopian tubes, &/or ovaries • In severe cases, surgical drainage may be required
o Sexually transmitted disease
ko
▪ Most commonly Neisseria gonorrhoeae or Chlamydia DIAGNOSTIC CHECKLIST

trachomatis
▪ 30-40% are polymicrobial Image Interpretation Pearls
oo
▪ Less common organisms include gram-negative • Use different scanning planes with US and MR or
rods, tuberculosis, actinomycosis multiplanar reformations with CT to prove a cystic
o Risk factors adnexal mass is actually dilated fallopian tube
eb
▪ Multiple sex partners or partner with multiple sex

partners SELECTED REFERENCES
▪ Intrauterine device
▪ Prior uterine procedure (e.g., D&C, biopsy)
://
1. Crittle KN et al: Diagnosis and treatment of pelvic

inflammatory disease: a quality assessment study. Obstet
Microscopic Features Gynecol. 123 Suppl 1:26S, 2014
• Fibrosis, acute and chronic inflammatory changes
tp
2. Lee MH et al: CT findings of acute pelvic inflammatory
• Sequelae include dense fibrosis and adhesions 3.

disease. Abdom Imaging. Epub ahead of print, 2014
Romosan G et al: The sensitivity and specificity of
ht
encompassing tubes, ovaries, and uterus transvaginal ultrasound with regard to acute pelvic
inflammatory disease: a review of the literature. Arch
Gynecol Obstet. 289(4):705-14, 2014
CLINICAL ISSUES 4. Greenstein Y et al: Tuboovarian abscess. Factors associated
Presentation with operative intervention after failed antibiotic therapy. J

Reprod Med. 58(3-4):101-6, 2013
Mitchell C et al: Pelvic inflammatory disease: current
o In mild cases, symptoms may be vague and concepts in pathogenesis, diagnosis and treatment. Infect
nonspecific Dis Clin North Am. 27(4):793-809, 2013
o Vaginal discharge 6. Chappell CA et al: Pathogenesis, diagnosis, and
o Pelvic pain management of severe pelvic inflammatory disease and
o Fever and elevated white blood cell count tuboovarian abscess. Clin Obstet Gynecol. 55(4):893-903,
o Cervical motion tenderness on exam 2012
o RUQ pain and abnormal liver function tests (Fitz- 7. Lewiss RE et al: Sonographic cervical motion tenderness: A
sign found in a patient with pelvic inflammatory disease.
Hugh-Curtis syndrome) Crit Ultrasound J. 4(1):20, 2012
Demographics 8. Levenson RB et al: Image-guided drainage of tuboovarian
• Age abscesses of gastrointestinal or genitourinary origin: a

retrospective analysis. J Vasc Interv Radiol. 22(5):678-86,
o Greatest incidence in young women (< 25 years)
6 2011
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PELVIC INFLAMMATORY DISEASE, GENERAL CONSIDERATIONS
Fallopian Tubes
(Left) Coronal reformatted
CECT in a young woman with
pelvic inflammatory disease
(PID) shows thick-walled
enhancing fallopian tubes
and bilateral enlarged
ovaries with complex cysts
. There were no drainable
collections, and she was treated
with antibiotic therapy. (Right)
CECT in a woman with severe
endometritis and a pyometrium
shows distended endometrial
cavity and fluid-debris level .
There are severe surrounding
inflammatory changes
t
obscuring the posterior border of
ne
the uterus, the "indefinite uterus"
sign.
e.
yn
(Left) Axial CECT through
the pelvis in a 28-year-old
woman with Fitz-Hugh-Curtis
bg syndrome, severe PID, and
abnormal liver function tests
shows bilateral thick-walled tubo-
ovarian abscesses . (Right)
ko
Axial CECT through the upper

abdomen in the same patient
shows periportal edema and
oo
regional perfusion abnormalities

due to perihepatitis from
peritoneal spread of infection.
eb
://
tp
ht
(Left) Coronal reformatted CECT

in a woman with PID shows
a dilated fallopian tube
with surrounding inflammatory
changes . The tubular nature
of a cystic adnexal mass can
often be better appreciated on
reformatted images. (Right)
Another image in the same case
shows a nonocclusive filling
defect in the right ovarian
vein, which is outlined by a
small amount of venous contrast.
Ovarian vein thrombosis is a
potential complication of PID.
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Fallopian Tubes HYDROSALPINX
Key Facts
Terminology • Primary fallopian tube carcinoma
• Dilated, fluid-filled fallopian tube • Peritoneal inclusion cysts
• Appendiceal mucocele
Imaging • Distended pelvic veins
• Tubular, fluid-filled juxtauterine structure
• Separate from ovary Pathology
• Folded configuration with C or S shape • Results from obstruction of ampullary segment of tube
• Incomplete septations • Dilatation of usually the ampullary and infundibular
• "Beads on a string" sign portions of tube
• Waist sign Clinical Issues
• Signal intensity depends on tube contents • Asymptomatic or can present with pelvic pain or
• Tube wall uniformly smooth & thin with mild infertility
enhancement; mucosal plicae are usually effaced • Seen in setting of obstruction, prior pelvic
inflammatory disease, endometriosis
• Salpingitis/pyosalpinx
• Cystic ovarian neoplasm
t
• Small bowel obstruction
ne
e.
yn
shows an anechoic tubular
structure with incomplete
septations . The ovary
bg
is not shown. (Right)
Hysterosalpingogram shows
dilation of the ampullary
ko
segment of the left fallopian
tube compatible with
hydrosalpinx. There is no spill
of contrast into the peritoneum
oo
on the left side indicating

occlusion of the tube.
eb
://
tp
ht

tubular fluid attenuation
structure in the right
hemipelvis containing an
incomplete septation . This
structure is separate from the
left ovary and not contiguous
with bowel loops. (Right) Axial
T2WI FSE MR shows a tubular
hyperintense structure in
the left hemipelvis, separate
from the ovary and bowel
loops. The wall is smooth and
thin.
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HYDROSALPINX
Fallopian Tubes
o Can distinguish from dilated bowel loops by absence
TERMINOLOGY
of peristalsis
Definitions o Presence of substantial adhesions may result in
• Dilated, fluid-filled fallopian tube atypical appearances and even simulate ovarian
neoplasm
IMAGING Imaging Recommendations

General Features
o US: Best initial imaging of female pelvis
• Best diagnostic clue o HSG: Assess tubal patency
o Fluid-filled tubular structure interposed between o MR
uterus and ovary ▪ If US confusing, can help to identify tubular nature
o Folded configuration with C or S shape and a separate ovary
o Incomplete septations ▪ Best to differentiate from other adnexal masses/
o No surrounding inflammation ovarian malignancy
Hysterosalpingography (HSG) ▪ Noninvasive assessment of peritubal environment
• Dilated fallopian tube(s) •
and peritubal disease
• No spill of contrast into peritoneum Protocol advice

o MR: Intravenous contrast is useful to exclude
• May see venous or lymphatic intravasation of contrast
t
fallopian tube cancer
o Nonspecific; can also be due to technique, seen with
ne
fibroids or during menstruation
CT Findings
• Fluid-attenuation tubular juxtauterine structure
e.
Salpingitis/Pyosalpinx
• Separate from ovary • Complex fluid in distended tube
• Separate from bowel by absence of intraluminal enteric • Wall thickening and surrounding inflammation
yn
contrast • Fever, pain, ↑ WBC
MR Findings Cystic Ovarian Neoplasm
bg
• T1WI • Can be confused with tumor with small internal
o Signal intensity (SI) depends on tube contents papillations and septae
▪ Simple fluid: Low SI o Tumor papillary formations are usually dissimilar in
ko
▪ Proteinaceous fluid: Intermediate to high SI size along a wall that may show variable thickness
• T2WI • No tubular structures
o High SI
oo
o Incomplete septa or folds Small Bowel Obstruction

o Tube wall uniformly smooth and thin, mucosal • Fluid-filled tubular structures located centrally in pelvis
and extend into abdomen
• Nausea, vomiting, absence of bowel movement
plicae are usually effaced
o Thin, longitudinally oriented folds along interior
eb
of tube represent incompletely effaced mucosal or Primary Fallopian Tube Carcinoma

submucosal plicae
• Fluid-filled tubular structure with larger mural nodules
•
://
T1WI C+
o Tube wall uniformly smooth and thin with mild Peritoneal Inclusion Cysts
enhancement • Trapping by peritoneal adhesions of fluid that is
tp
o No associated inflammation normally produced by active ovaries

• Similar causative factors to that of hydrosalpinx
• Ovary is characteristically surrounded by septations
ht
• Grayscale ultrasound and fluid

o Tubular anechoic adnexal mass
o Separate from ovary • In hydrosalpinx, ovary is not surrounded by a cystic
lesion (dilated tube) but rather adjacent to and separate
o Thin echogenic wall
from it
▪ Thickening of tube wall > 5 mm in 3%
o Incomplete septations • Does not present with echogenic walls
▪ Folding of distended tube • Adhesions may extend across entire width of a
fluid collection unlike incomplete septations in
▪ Seen in longitudinal section
hydrosalpinx
o "Beads on a string" sign
▪ Hyperechoic mural nodules (2-3 mm) Appendiceal Mucocele
▪ Degenerated, flattened endosalpingeal fold • Arises from cecum, seen best on CT or MR
remnants • Difficult to differentiate with US
▪ Seen in cross section
▪ Indicator of chronic disease (57% of chronic cases) Distended Pelvic Veins
o Waist sign • Also have a tubular appearance when imaged along
▪ Indentations of tube wall directly opposite each their long axis
• Blood flow within produces multiple low-level moving
other
echoes on real-time sonography 6
11
Obgyne Books Full
Fallopian Tubes HYDROSALPINX
• Color Doppler may establish diagnosis if flow is 3. Rezvani M et al: Fallopian tube disease in the nonpregnant
patient. Radiographics. 31(2):527-48, 2011
detected
• When flow is too slow, spectral Doppler can be 4. Moyle PL et al: Nonovarian cystic lesions of the pelvis.
Radiographics. 30(4):921-38, 2010
performed to confirm venous flow
5. Kim MY et al: MR Imaging findings of hydrosalpinx: a
comprehensive review. Radiographics. 29(2):495-507, 2009
PATHOLOGY 6. Patel MD et al: Likelihood ratio of sonographic findings in
discriminating hydrosalpinx from other adnexal masses.
General Features AJR Am J Roentgenol. 186(4):1033-8, 2006
• Etiology 7. Imaoka I et al: MR imaging of disorders associated with
female infertility: use in diagnosis, treatment, and
o Results from obstruction of ampullary segment of
management. Radiographics. 23(6):1401-21, 2003
tube 8. Bennett GL et al: Gynecologic causes of acute pelvic pain:
▪ Most common cause is adhesions from prior spectrum of CT findings. Radiographics. 22(4):785-801,
episodes of PID 2002
– Usually a result of chlamydial or gonococcal 9. Sam JW et al: Spectrum of CT findings in acute pyogenic
infection pelvic inflammatory disease. Radiographics. 22(6):1327-34,
▪ Tubal ligation 2002
▪ Hysterectomy without salpingo-oophorectomy 10. Dohke M et al: Comprehensive MR imaging of acute
gynecologic diseases. Radiographics. 20(6):1551-66, 2000
▪ Endometriosis 11. Guerriero S et al: Transvaginal ultrasonography
▪ Tubal malignancy
t
associated with colour Doppler energy in the diagnosis of
ne
hydrosalpinx. Hum Reprod. 15(7):1568-72, 2000
• Dilatation of usually the ampullary and infundibular
12. Jain KA: Imaging of peritoneal inclusion cysts. AJR Am J
Roentgenol. 174(6):1559-63, 2000
portions of tube 13. Thurmond AS: Sonographic imaging in infertility. In Callen
• Tube usually contains clear serous fluid
e.
PW: Ultrasonography in Obstetrics and Gynecology. 4th ed.
• When thin-walled, tube grossly distended with straw- 14.
Philadelphia: Saunders. 897-911, 2000
Outwater EK et al: Dilated fallopian tubes: MR imaging
yn
colored fluid, which makes it appear translucent
• If chronic, thick-walled with fibrous wall, small lumen, 15.
characteristics. Radiology. 208(2):463-9, 1998
Timor-Tritsch IE et al: Transvaginal sonographic markers of
and contains little fluid
tubal inflammatory disease. Ultrasound Obstet Gynecol.
bg 12(1):56-66, 1998
• Most of the epithelial lining is flattened and cuboidal 16. Kim JS et al: Peritoneal inclusion cysts and their relationship
• Occasional plica with intact columnar epithelium may

to the ovaries: evaluation with sonography. Radiology.
204(2):481-4, 1997
ko
persist 17. Atri M et al: Accuracy of endovaginal sonography for the

detection of fallopian tube blockage. J Ultrasound Med.
13(6):429-34, 1994
CLINICAL ISSUES
oo
18. Atri M et al: Endovaginal sonographic appearance of benign

ovarian masses. Radiographics. 14(4):747-60; discussion
Presentation
• Usually asymptomatic
761-2, 1994
19. Cacciatore B et al: Transvaginal sonographic findings in
• Can present with pelvic pain or infertility
eb
ambulatory patients with suspected pelvic inflammatory

• Seen in setting of obstruction, prior pelvic 20.
disease. Obstet Gynecol. 80(6):912-6, 1992
Terry J et al: Sonographic demonstration of salpingitis.
inflammatory disease, endometriosis
• Detected incidentally or in setting of infertility work-up Potential confusion with appendicitis. J Ultrasound Med.
://
• Its presence bilaterally is diagnostic of tubal infertility

8(1):39-41, 1989
21. Tessler FN et al: Endovaginal sonographic diagnosis of
tp
dilated fallopian tubes. AJR Am J Roentgenol. 153(3):523-5,

Treatment
• Surgical: Lysis of adhesions, fimbrioplasty (freeing up
1989
ht
fimbria) or tuboplasty (creating new fimbria)

• Radiologic catheter recanalization for proximal tubal
obstruction (similar to angioplasty)
• Extraovarian tubular structure with incomplete
septations
SELECTED REFERENCES
1. Laing FC et al: US of the ovary and adnexa: to worry or not
to worry? Radiographics. 32(6):1621-39; discussion 1640-2,
2012
2. Pampal A et al: A rare cause of acute abdominal pain in
adolescence: hydrosalpinx leading to isolated torsion of
fallopian tube. J Pediatr Surg. 47(12):e31-4, 2012
6
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Obgyne Books Full
HYDROSALPINX
Fallopian Tubes
(Left) Hysterosalpingogram
shows that the left fallopian tube
is not opacified past the isthmic
portion , compatible with
occlusion. There is intravasation
of contrast due to increased
pressure with tubal obstruction.
shows the dilated fallopian tube
in cross section. The tube
contents are anechoic with
posterior acoustic enhancement.
The hyperechoic mural nodules
represent the flattened
endosalpingeal folds seen in
chronic hydrosalpinx.
t
ne
e.
yn
(Left) Axial T2WI FSE MR in the
same patient shows a tubular
hyperintense structure with
bg an incomplete septation .
Ovary (not shown) and bowel
loops are separate. (Right)
ko

dilated fallopian tube in
cross section demonstrating the
oo
endosalpingeal folds . The

tubular shape of hydrosalpinx
is seen best on MR, but the
endosalpingeal folds are better
eb
demonstrated on the above US.

://
tp
ht
(Left) Transabdominal ultrasound

shows the uterus and a
nonspecific cystic right adnexal
mass . The patient refused
transvaginal ultrasound. (Right)
tubular hyperintense structure
interposed between the uterus
and ovary . Contiguous
images further confirmed the
tubular shape and lack of
mural nodules in this case of
hydrosalpinx. MR is best for
demonstrating a separate ovary
and tube characteristics.
6
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Fallopian Tubes PYOSALPINX
Key Facts
Terminology • Pelvic inflammatory stranding and fluid
• Acute salpingitis • Peritoneal thickening and enhancement
o Inflammation of fallopian tubes
• Pyosalpinx • Hydrosalpinx
o Inflammation of fallopian tubes with obstruction
• Hematosalpinx
• Ectopic pregnancy
and distention with pus
Imaging • Adnexal torsion
• Tubular adnexal structure distended with complex • Small bowel obstruction
fluid and debris
• Thick hypervascular wall ≥ 5 mm Pathology
• Incomplete septations; cog wheel sign • Commonly due to bacterial infection
• Hypointense to intermediate signal intensity content Clinical Issues
on T1WI
• Intermediate to high signal intensity content on T2WI • Fever, abdominal and pelvic pain
• Typically bilateral • Sexually active women
• Oophoritis; endometritis with poor definition of
t
ne
endometrial echo complex
e.
yn
with bilateral salpingitis
shows a tubular thick-walled
hyperenhancing structure
bg
in the left hemipelvis
extending to the left ovary
ko
the hyperenhancing thick-
walled left fallopian tube
with inflammation of the
oo
surrounding pelvic fat

and peritoneal thickening
. Hyperenhancement of
eb
the endometrium and

fluid in the uterine cavity
are partially visualized and
indicative of accompanying
://
endometritis.
tp
ht

with pyosalpinx shows a
tubular left adnexal structure
with thick enhancing
walls and inflammation
of the adjacent pelvic fat
. Separate left ovary is
not shown. (Right) Coronal
shows the dilated left
fallopian tube in short axis
. Note the thickening and
hyperenhancement of the tube
wall and endosalpingeal folds.
6
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PYOSALPINX
Fallopian Tubes
TERMINOLOGY • Endometritis with poor definition of endometrial echo
complex
Definitions • Pelvic inflammation
• Salpingitis: Inflammation of fallopian tubes o Increased echogenicity of pelvic fat with ill-defined
• Pyosalpinx: Inflammation of fallopian tubes with uterus
o Increased vascularity of peritubal/pelvic fat
obstruction and distention with pus
IMAGING • Best imaging tool
o Ultrasound
General Features ▪ Initial modality in female with pelvic pain
• Best diagnostic clue ▪ Optimal for identification of ovaries and exclusion
o Tubular adnexal mass with wall thickening ±
of torsion or ectopic pregnancy
distention o CT
o Inflammatory changes in pelvic fat ▪ Useful if symptoms are nonspecific to exclude
o Peritoneal thickening and enhancement
nongynecologic diagnoses
• Location ▪ Helps to identify patients requiring hospitalization
o Typically bilateral ▪ Useful if known PID to assess for accessibility for
CT Findings percutaneous drainage
t
o MR
• CECT
ne
▪ Aids in identifying ovary
o May be normal in mild cases of salpingitis
▪ Helps differentiate pyosalpinx from hematosalpinx
o Wall thickening and hyperenhancement of fallopian
▪ Demonstrates tubular nature of a structure to
tubes
e.
o Distention of tube with complex fluid exclude ovarian malignancy
o Enlarged, indistinct but separate ovaries • Protocol advice
o CT: IV and oral contrast timed to opacify distal small
yn
o Oophoritis
▪ Enlarged, edematous ovaries bowel
o MR: Fat-suppression on T2WI and T1 C+ images
▪ Polycystic appearance
▪ Increased stromal enhancement improves visualization of inflammatory changes
bg
▪ Indistinct contours, but separate with preserved
architecture DIFFERENTIAL DIAGNOSIS
o Pelvic inflammatory stranding and fluid
ko
o Peritoneal thickening and enhancement Hydrosalpinx

• Tube distended with simple fluid
MR Findings
• T1WI • No wall thickening or surrounding inflammation
oo
o Tube contents: Hypointense to intermediate signal Hematosalpinx

intensity • Avascular blood-filled fallopian tube
• • No pelvic fat inflammation
eb
T2WI
o Tube contents: Intermediate to high signal intensity
o Hyperintense bands of inflammation and fluid in
• Easily differentiated on MR
Ectopic Pregnancy
://
pelvic fat
• T1WI C+ FS • Positive serum β-hCG
o Wall thickening and hyperenhancement of fallopian • Generally rounded or oval-shaped, extraovarian, solid
tp
tubes ± distention adnexal mass

o Enhancing bands in pelvic fat • No inflammation of fat
o Peritoneal thickening and enhancement • Unilateral
ht
Ultrasonographic Findings Adnexal Torsion

• Tubular adnexal structure distended with echogenic • Twisted pedicle sign
fluid and debris • Normal to diminished vascularity of adnexa
o May contain fluid-debris level
o Incomplete septations
• More significant enlargement of ovary
o Thick hypervascular wall ≥ 5 mm • Less inflammation of pelvic fat
o Cog wheel sign • Unilateral
▪ Short linear projections seen in cross section Small Bowel Obstruction
▪ Thickened endosalpingeal folds • Tubular fluid-filled pelvic structure are contiguous with
▪ Sensitive marker of acute disease bowel on CT
• Oophoritis
o Ovarian enlargement
o Indistinct contours PATHOLOGY
o Polycystic appearance General Features
o Periovarian fluid
• Etiology
6
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Fallopian Tubes PYOSALPINX
o Salpingitis: Edematous inflamed fallopian tubes due Treatment

to ascending infection from uterine cavity
o Pyosalpinx: Inflammation results in tubal and
• IUD removed if present
• Antibiotic therapy
peritubal adhesions causing obstruction of fimbrial
• Image-guided or surgical drainage of pelvic abscess
• Transvaginal, transrectal, or laparoscopic tuboplasty in
end and distention with pus
o Most commonly due to bacterial infection
▪ Most common organisms are Neisseria gonorrhoeae patients with infertility and confirmed tube blockage
or Chlamydia trachomatis
▪ 30-40% polymicrobial DIAGNOSTIC CHECKLIST
▪ Granulomatous, fungal, and parasitic infections
can also be seen Consider
o Risk factors • Thickened FT as a cause of apparent "ovarian
▪ Young age enlargement" in appropriate clinical setting
▪ Multiple sexual partners o FT may be closely related/adherent to ovary and, as
▪ High coital frequency such, mistaken for ovary
▪ Low socioeconomic status Image Interpretation Pearls
▪ Intrauterine contraceptive device
– 3x increased risk of PID
• Patient very tender on TVUS examination
– PID occurs within first few months of insertion • Thickened/distended fallopian tube
• Inflamed adnexal fat
t
– Higher occurrence of actinomycosis
ne
• Thickened inflamed fallopian tubes covered by SELECTED REFERENCES
e.
fibrinous exudates and pus exuding from fimbriated 1. Romosan G et al: Ultrasound for diagnosing acute
end salpingitis: a prospective observational diagnostic study.
Hum Reprod. 28(6):1569-79, 2013
yn
Microscopic Features 2. Le Pennec V et al: Imaging in infections of the left iliac fossa.
• Purulent inflammatory process results in cell lysis and 3.
Diagn Interv Imaging. 93(6):466-72, 2012
Rezvani M et al: Fallopian tube disease in the nonpregnant
sloughing, vascular engorgement, and edema of all
tubal layers
bg
• Fibrinous exudates on serosal surface in severe cases 4. Horrow MM: Ultrasound of pelvic inflammatory disease.
Ultrasound Q. 20(4):171-9, 2004
5. Nishie A et al: Fitz-Hugh-Curtis syndrome. Radiologic
ko
CLINICAL ISSUES manifestation. J Comput Assist Tomogr. 27(5):786-91, 2003

6. Nishino M et al: Magnetic resonance imaging findings
Presentation in gynecologic emergencies. J Comput Assist Tomogr.
• Most common signs/symptoms 27(4):564-70, 2003
oo
7. Varras M et al: Tubo-ovarian abscesses: spectrum of

o Fever sonographic findings with surgical and pathological
o Abdominal and pelvic pain correlations. Clin Exp Obstet Gynecol. 30(2-3):117-21, 2003
▪ Due to cell necrosis, distension of tube(s), and focal
eb
8. Bennett GL et al: Gynecologic causes of acute pelvic pain:

peritonitis spectrum of CT findings. Radiographics. 22(4):785-801,
o Mucopurulent vaginal discharge, uterine bleeding 2002
o Up to 35% of patients with PID are asymptomatic 9. Sam JW et al: Spectrum of CT findings in acute pyogenic
•
://
pelvic inflammatory disease. Radiographics. 22(6):1327-34,

2002
o Gonococcal salpingitis has typical onset of pain a few 10. Ueda H et al: Adnexal masses caused by pelvic inflammatory
tp
days after menses disease: MR appearance. Magn Reson Med Sci. 1(4):207-15,
▪ Gonococcus gains access to tubes most easily 2002
during menstruation 11. Bau A et al: Acute female pelvic pain: ultrasound evaluation.
ht
Semin Ultrasound CT MR. 21(1):78-93, 2000

Demographics 12. Nelson AL et al: Transrectal ultrasonographically guided
• Epidemiology drainage of gynecologic pelvic abscesses. Am J Obstet
o Sexually active women Gynecol. 182(6):1382-8, 2000
o PID affects > 1 million women 13. Corsi PJ et al: Transvaginal ultrasound-guided aspiration
o PID accounts for over 275,000 hospitalizations/year of pelvic abscesses. Infect Dis Obstet Gynecol. 7(5):216-21,
1999
Natural History & Prognosis 14. Hawnaur JM et al: Magnetic resonance imaging of
• Causes tubal damage, scarring, and occlusion actinomycosis presenting as pelvic malignancy. Br J Radiol.
72(862):1006-11, 1999
o 6x increased risk of ectopic pregnancy
15. McCormack WM: Pelvic inflammatory disease. N Engl J
o Increased risk of future episodes of PID Med. 330(2):115-9, 1994
o Hydrosalpinx
o Chronic pelvic pain in up to 20%
o Infertility
▪ 8% after a single episode of PID
▪ 20% after 2 episodes
▪ 40% after 3 episodes
6
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Obgyne Books Full
PYOSALPINX
Fallopian Tubes
(Left) Color Doppler ultrasound
image in a patient with
pyosalpinx shows a normal
ovary containing multiple
follicles. Adjacent to the ovary
is the dilated fallopian tube with
thickening of the endosalpingeal
folds known as the cog
wheel sign. (Right) Transverse
ultrasound image in the same
patient shows the tube distended
with complex echogenic fluid
and containing a fluid-fluid
level . Ultrasound is the best
modality for demonstrating a
separate ovary and complex
t
nature of fluid.
ne
e.
yn
patient shows a tubular right
adnexal mass with thick
bg enhancing wall and incomplete
septations compatible with the
pyosalpinx seen on ultrasound.
Note similar findings in the left
ko
adnexa compatible with

pyosalpinx. (Right) Axial CECT
oo
dilated inflamed right fallopian

tube and separate but ill-
defined right ovary indicative
of oophoritis. The ovary was
eb
shown to better advantage on

the ultrasound. Again, note left
pyosalpinx .
://
tp
ht

bilateral fluid-filled tubular
adnexal masses with
thickened hypervascular wall.
The ovaries are separate, not
shown. There is surrounding
pelvic fat stranding and free
peritoneal fluid . (Right)
patient shows fluid distension
of the uterine cavity and
hyperenhancement of the
endometrium consistent with
endometritis. Salpingitis and
pyosalpinx are due to ascending
infection; therefore, endometritis
and oophoritis may also be seen.
6
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Obgyne Books Full
Fallopian Tubes TUBO-OVARIAN ABSCESS
Key Facts
Terminology • Septal and thick rim enhancement
• Advanced PID resulting in destruction of normal • May have ↑ T1 rim along inner wall of abscess cavity
structures with formation of an inflammatory mass • Mesh-like stranding in pelvic fat on T2WI & T1WI +C
encompassing both fallopian tube and ovary
Imaging • Ovarian neoplasm
• Complex solid and cystic adnexal mass • Adnexal torsion
• Internal septations and mural irregularity • Hemorrhagic ovarian cyst/endometriosis
• May have fluid-debris level • Pelvic abscess from another cause
• Internal gas is rare
• Pelvic inflammation and free fluid Pathology
• Fitz-Hugh-Curtis syndrome • Most commonly due to bacterial infection
o Peritoneal spread of infection via right paracolic • Rupture of TOA may cause life threatening peritonitis
gutter to involve peritoneal surfaces of right upper Clinical Issues
quadrant
o Perihepatitis, inflammation of Glisson capsule • Fever, pelvic pain, discharge
o Gallbladder wall thickening, pericholecystic fluid • Sexually active women
t
• • Can lead to infertility and ectopic pregnancies
ne
Heterogeneous adnexal mass on T1 & T2
e.
yn
shows a left adnexal mass
with solid and cystic
components in this patient
bg
with tubo-ovarian abscess.
Note posterior acoustic
enhancement. A normal ovary
ko
could not be identified. (Right)
shows the complex left adnexal
mass with central fluid
oo
and thick rim enhancement.

Surrounding fat stranding
is indicative of inflammation. A
eb
normal ovary was not present

and the left ovarian vessels
terminated in this structure.
://
tp
ht

shows the left tubo-ovarian
abscess with fluid centrally
and a thick irregular wall .
The complexity of the central
cystic component is seen best
on the T2WI. Surrounding
pelvic inflammation is harder
to see due to the lack of fat
saturation. (Right) Axial T1WI
C+ FS MR shows the thick
rim enhancement typical
of a tubo-ovarian abscess.
Note mesh-like stranding
in pelvic fat. Normal ovarian
or fallopian tube architecture
has been destroyed by the
advanced infection.
6
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Obgyne Books Full
TUBO-OVARIAN ABSCESS
Fallopian Tubes
TERMINOLOGY ▪ Thick irregular wall
o Hemorrhagic or proteinaceous material can be
Abbreviations hyperintense
• Tubo-ovarian abscess (TOA) o May have hyperintense rim along inner wall of
abscess cavity
Definitions ▪ Granulation tissue and hemorrhage
• Infection of upper female genital tract including • T2WI
endometrium, fallopian tubes, and ovaries o Ill-defined heterogeneous adnexal mass
• Advanced acute pyogenic pelvic inflammatory disease ▪ Contains intermediate to high signal fluid
(PID) resulting in destruction of normal structures with ▪ Hypointense thick irregular wall and septations
formation of an inflammatory mass encompassing o Hyperintense edema in parametrial fat
both fallopian tube and ovary o Hypointense linear fibrous stranding in pelvic fat
• T1WI C+
IMAGING o Septal and thick rim enhancement of adnexal mass
o Mesh-like stranding in pelvic fat
General Features ▪ Corresponds to adhesions and fibrosis
o Fallopian tube and ovary not identified as discrete
entities; rather, together form tubo-ovarian complex • Multilocular complex adnexal mass
• Thick wall and septations, mural irregularity
t
o Complex adnexal mass
ne
▪ Solid and cystic • May have fluid-debris level
▪ Internal septations and mural irregularity • Increased echogenicity of pelvic fat due to
▪ May have fluid-debris level inflammation
e.
▪ Internal gas is rare
o Pelvic inflammation and free fluid Imaging Recommendations
o Secondary involvement of adjacent structures • Best imaging tool
yn
▪ Ileus, obstruction, or reactive bowel wall o US
thickening ▪ Initial modality in female with pelvic pain
▪ Ureteropelvicaliectasis (functional or mechanical ▪ Optimal for exclusion of ovarian torsion or ectopic
bg
obstruction) pregnancy
▪ Intraperitoneal abscess if TOA ruptures o CT
▪ Useful if symptoms are nonspecific to exclude
• Fitz-Hugh-Curtis syndrome
ko
o Complication of PID nongynecologic diagnoses

o Peritoneal spread of infection via right paracolic ▪ Helps to identify patients requiring hospitalization
▪ Useful if known PID to assess for accessibility for
gutter to involve peritoneal surfaces of right upper
oo
quadrant percutaneous drainage

o Perihepatitis, inflammation of Glisson capsule o MR
▪ Thickening and enhancement of anterior liver ▪ Helps differentiate from ovarian malignancy and
eb
endometriosis
•
capsule
▪ Subcapsular and periportal geographic areas of Protocol advice
o CT: IV and oral contrast timed to opacify distal small
hepatic perfusional variation
o Gallbladder wall thickening and pericholecystic fluid bowel
://
o Fluid and stranding in right paracolic gutter o MR: Fat suppression on T2WI and T1WI C+ improves
o Peritoneal septa, loculated perihepatic fluid visualization of inflammatory changes
tp
o MR may help if hepatic parenchymal abnormalities

are confusing on CT DIFFERENTIAL DIAGNOSIS
▪ Subcapsular and periportal geographic areas of
ht
hypervascularity in late arterial phase Ovarian Neoplasm

▪ Isointense on delayed postcontrast sequences • Mixed cystic solid lesion
▪ No corresponding signal abnormality on • No pelvic inflammation
precontrast sequences • Large amount of free fluid
CT Findings • ± peritoneal deposits
• CECT • No clinical signs of pain and infection
o Multilocular adnexal mass
Adnexal Torsion
▪ Thick enhancing wall and septa
▪ Internal gas uncommon, but specific • Ovary is enlarged and edematous, but architecture is
preserved
o Pelvic fat stranding and fluid
o Thickening and enhancement of peritoneum and • Twisted pedicle sign
• Normal to diminished vascularity of adnexa
• Less pelvic inflammation
uterine ligaments
MR Findings
• T1WI Hemorrhagic Ovarian Cyst/Endometriosis
o Ill-defined adnexal mass • High signal on T1WI
▪ Contains low signal fluid • T2 shading 6
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Fallopian Tubes TUBO-OVARIAN ABSCESS
• Little or no pelvic fat stranding ▪ 40% after 3 episodes

• No clinical signs of infection Treatment
Pelvic Abscess From Another Cause • IUD removed if present
• Complex cystic mass • Antibiotic therapy
• e.g., diverticulitis, Crohn, ruptured appendicitis • Image-guided or surgical drainage of pelvic abscess
• Should have normal ovary or peripheral involvement
• Unilateral rather than bilateral DIAGNOSTIC CHECKLIST
• Presence of gas more common than for TOA Image Interpretation Pearls
PATHOLOGY
• Unilocular/multilocular adnexal mass with wall and
septal enhancement
General Features • No normal ovary; encompassed by inflammatory mass
• Etiology • Pelvic inflammation and fluid
o Results from untreated or unrecognized ascending • Peritoneal and uterine ligament thickening and
infection that progresses to endometritis, salpingitis, hyperenhancement
then tubo-ovarian abscess
o Postmenopausal tubo-ovarian abscesses may SELECTED REFERENCES
t
be associated with concomitant gynecological
ne
1. Greenstein Y et al: Tuboovarian abscess. Factors associated
malignancy in up to 50% of cases with operative intervention after failed antibiotic therapy. J
o Most commonly due to bacterial infection
Reprod Med. 58(3-4):101-6, 2013
▪ Most common organisms are Neisseria gonorrhoeae 2. Eshed I et al: Differentiation between right tubo-ovarian
e.
or Chlamydia trachomatis abscess and appendicitis using CT--a diagnostic challenge.
▪ 30-40% polymicrobial Clin Radiol. 66(11):1030-5, 2011
▪ Rare causes: Actinomycosis, TB, 3. Lee DC et al: Sensitivity of ultrasound for the diagnosis of
yn
xanthogranulomatous inflammation tubo-ovarian abscess: a case report and literature review. J
o Risk factors Emerg Med. 40(2):170-5, 2011
4. Rezvani M et al: Fallopian tube disease in the nonpregnant
▪ Young age
bg patient. Radiographics. 31(2):527-48, 2011
▪ Multiple sexual partners 5. Kim MY et al: MR Imaging findings of hydrosalpinx: a
▪ High coital frequency comprehensive review. Radiographics. 29(2):495-507, 2009
▪ Low socioeconomic status 6. Jeong WK et al: Tubo-ovarian abscess: CT and pathological
▪ Intrauterine contraceptive device
ko
correlation. Clin Imaging. 31(6):414-8, 2007
– 3x increased risk of PID 7. Uslu H et al: 99mTc-HMPAO labelled leucocyte scintigraphy
– PID occurs within 1st few months of insertion in the diagnosis of pelvic inflammatory disease. Nucl Med
Commun. 27(2):179-83, 2006
oo
– Higher occurrence of actinomycosis

8. Hiller N et al: Computed tomographic features of
tuboovarian abscess. J Reprod Med. 50(3):203-8, 2005
o Rupture of TOA may cause life threatening peritonitis 9. Kitamura Y et al: Imaging manifestations of complications
eb
associated with uterine artery embolization. Radiographics.

25 Suppl 1:S119-32, 2005
CLINICAL ISSUES 10. Kim SH et al: Unusual causes of tubo-ovarian abscess: CT
and MR imaging findings. Radiographics. 24(6):1575-89,
Presentation
://

2004
11. Harisinghani MG et al: Transgluteal approach for
o Nonspecific symptoms percutaneous drainage of deep pelvic abscesses: 154 cases.
tp
▪ Fever, abdominal or pelvic pain Radiology. 228(3):701-5, 2003

▪ Mucopurulent vaginal discharge, uterine bleeding 12. Varras M et al: Tubo-ovarian abscesses: spectrum of
▪ Cervical/adnexal tenderness, dyspareunia
ht
sonographic findings with surgical and pathological

▪ Dysuria, nausea, vomiting correlations. Clin Exp Obstet Gynecol. 30(2-3):117-21, 2003
o Up to 35% of patients with PID are asymptomatic 13. Sam JW et al: Spectrum of CT findings in acute pyogenic
pelvic inflammatory disease. Radiographics. 22(6):1327-34,
Demographics 2002
• Age 14. Bau A et al: Acute female pelvic pain: ultrasound evaluation.
Semin Ultrasound CT MR. 21(1):78-93, 2000
o Sexually active women 15. Tukeva TA et al: MR imaging in pelvic inflammatory
• Epidemiology disease: comparison with laparoscopy and US. Radiology.
o PID affects > 1 million women 210(1):209-16, 1999
o PID accounts for > 275,000 hospitalizations/year 16. Ha HK et al: MR imaging of tubo-ovarian abscess. Acta
Radiol. 36(5):510-4, 1995
Natural History & Prognosis 17. McCormack WM: Pelvic inflammatory disease. N Engl J
• Causes tubal damage, scarring, and occlusion Med. 330(2):115-9, 1994
o 6x increased risk of ectopic pregnancy 18. Wilbur AC et al: CT findings in tuboovarian abscess. AJR Am
o J Roentgenol. 158(3):575-9, 1992
Increased risk of future episodes of PID
19. Lande IM et al: Adnexal and cul-de-sac abnormalities:
o Chronic pelvic pain in up to 20% transvaginal sonography. Radiology. 166(2):325-32, 1988
o Infertility
▪ 8% after a single episode of PID
6 ▪ 20% after 2 episodes
20
Obgyne Books Full
TUBO-OVARIAN ABSCESS
Fallopian Tubes
in a patient with bilateral tubo-
ovarian abscesses shows a
complex solid and cystic left
adnexal mass. The right adnexa
was similar in appearance.
Normal ovaries were not seen.
patient shows bilateral complex
adnexal masses with thick rim
and septal enhancement, as well
as central areas of low density.
There is inflammatory stranding
of the pelvic fat, free fluid, and
thickening of the peritoneum.
t
ne
e.
yn
(Left) Axial CECT shows a large
with thick wall and septal
bg enhancement consistent with
a tubo-ovarian abscess. There
is no normal separate ovary.
ko
same patient shows best the

inflammation surrounding this
large tubo-ovarian abscess .
oo
eb
://
tp
ht

with a tubo-ovarian abscess
shows diffuse wall thickening
of a nondistended gallbladder.
There is free fluid in the
hepatorenal fossa . (Right)
patient shows the right tubo-
ovarian abscess with
inflammation extending along
the ovarian vascular pedicle
. Fluid and stranding is noted
in the right paracolic gutter
. Spread of inflammation
to the right upper quadrant is
compatible with Fitz-Hugh-Curtis
syndrome.
6
21
Obgyne Books Full
Fallopian Tubes GENITAL TUBERCULOSIS
Key Facts
Imaging o Marked enhancement of walls/septa of adnexal
• Hysterosalpingography (HSG) masses with inner wall serration/nodularity
o Diffusely thickened, avidly enhancing endometrium
o Tubal obstruction, mainly at isthmus and ampulla o ↑ T2 LAD due to liquefactive necrosis/caseation
o Tufted appearance of ampulla o Lymph node rim enhancement most common
o
•
Multiple FT constrictions: Beaded appearance
o US
Featureless "rigid pipe stem" appearance
o o Dilated FT with thickened wall
Peritubal adhesions with convoluted or corkscrew
o Solid or complex cystic adnexal masses
FT, loculated spillage of contrast material
o Endometrial thickening ± fluid
• CT
o Dilated FT with simple or dense fluid (25-45 HU) Top Differential Diagnoses
o Tubal wall thickened showing marked enhancement
o Mixed density solid/complex cystic adnexal masses
• PID/actinomycosis
o Characteristic high-density (20–45 HU) ascites • Ovarian carcinoma
o Nodular peritoneal enhancement, omental cake, Clinical Issues
stellate mesenteric mass
o LAD common, typical rim enhancement
• Infertility, pelvic pain, fever, dysmenorrhea
• CA125 may be ↑ due to peritoneal inflammation
•
t
MR
o Multiloculated cystic or solid adnexal masses
ne
e.
yn
ultrasound of the left adnexa
shows a tubular thick-walled
structure extending to
bg
the left ovary , consistent
with salpingitis. There is also
complex peritoneal fluid. The
ko
fallopian tube is involved in
almost all cases of genital
tuberculosis. (Right) Transverse
oo
shows increased flow in the

inflamed fallopian tube.
eb
://
tp
ht

in a patient with genital
tuberculosis shows a
thickening of the left fallopian
tube, a portion of which is
visible on this image .
The normal fallopian tube
is typically not visible on
imaging. Note also the free
fluid and smooth peritoneal
thickening . (Right) Coronal
oblique T2WI FSE MR shows
the thickened isthmic portion
of the fallopian tube
outlined by free peritoneal
fluid.
6
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Obgyne Books Full
GENITAL TUBERCULOSIS
Fallopian Tubes
TERMINOLOGY ▪ Featureless "rigid pipe stem" appearance
o Peritubal adhesions
Abbreviations ▪ Convoluted or corkscrew FT, loculated spillage of
• Tuberculosis (TB) contrast material
o Endometrial tuberculosis
Synonyms ▪ Irregular and stellate synechiae with well-
• Female genital TB demarcated borders
• TB pelvic inflammatory disease ▪ Pseudounicornuate uterus due to obliteration of
• TB salpingitis cavity on 1 side
Definitions CT Findings
• Infection of female genital tract by Mycobacterium • NECT
tuberculosis o Superior for demonstrating calcification of FTs,
ovaries, and periadnexal nodes
IMAGING •CECT
o Dilated FT with simple or dense fluid (25-45 HU)
General Features ▪ Tubal wall thickened showing marked
• Best diagnostic clue enhancement
o Mixed density solid/complex cystic adnexal masses
o Klein diagnostic criteria
t
▪ Calcified nodes or small, irregular calcifications in o Characteristic high-density (20–45 HU) ascites
ne
adnexal area ▪ Multiloculated collections in cul-de-sac
▪ Obstruction of fallopian tube (FT) in zone of o Thickening and nodularity of peritoneal surfaces,
transition between isthmus and ampulla mesentery, omentum, bowel wall
▪ Nodular peritoneal enhancement
e.
▪ Multiple FT constrictions (beading)
▪ Endometrial adhesion ± deformity or obliteration ▪ "Omental cake" or nodular infiltration
▪ Stellate appearance of mesenteric mass due to
yn
of endometrial cavity
• Location fixing of bowel and mesentery
o Lymphadenopathy common
o Involvement is typically bilateral
o FT (95%), followed by endometrium (60-70%), ▪ Typical: Peripheral rim enhancement of enlarged
bg
peritoneum (50%), ovary (15%), and cervix (5%) nodes with hypodense centers
▪ Less common: Homogeneous, low-density nodes
• Tubo-ovarian abscesses: Bilateral complex cystic and
o Inflammatory changes including thickening of
solid adnexal masses ± calcification
ko
o May extend through peritoneum into ligaments and obliteration of fat planes
extraperitoneal compartment MR Findings
• Endometritis (60%) • T1WI
oo
o Diffuse endometrial thickening o Multiloculated cystic adnexal masses

o Fluid within endometrial cavity ▪ Irregularly thickened walls/septa of intermediate to
o Synechiae high signal intensity (SI)
•
eb
Peritonitis (50%) o Hydrosalpinx of variable SI: Intermediate to high

o "Wet-type" with ascites is most common (90%)
▪ Large amounts of free or loculated fluid
•T2WI
o Multiloculated cystic adnexal masses
▪ Transudate early on, becomes complex later
://
▪ Irregularly thickened walls/septa of low SI

o "Dry or plastic-type" peritonitis is least common ▪ Fluid contents variable: Intermediate to high SI
(10%) o Predominantly solid adnexal masses
tp
▪ Caseous lymph nodes, peritoneal fibrosis and ▪ Mottled high SI (caseation) on background of low
adhesions SI (dense fibrosis)
•
ht
"Omental cake" or nodular infiltration of omentum o Diffusely thickened, iso- to hypointense

• Mesenteric mass with stellate appearance endometrium
• Lymphadenopathy: More common with abdominal TB ▪ Pyometra: Intermediate to high SI
o Typically multiple and large, 2-3 cm in diameter ▪ Synechiae: Low SI bands traversing cavity
• Bowel wall thickening, strictures, and fistula formation o Intermediate SI of plaque-like or nodular peritoneal
deposits
Radiographic Findings o Majority of enlarged nodes demonstrating high SI
• Radiography due to liquefactive necrosis/caseation
o Healed or active pulmonary TB on chest radiograph ▪ Obliteration of perinodal fat with high SI due to
▪ Normal chest radiograph in up to 75% of cases capsular disruption
• Hysterosalpingography (HSG) ▪ Central nodal hypointensity due to paramagnetic
o Tubal obstructive findings are most common, mainly free radicals of active phagocytic cells
at isthmus and ampulla •T1WI C+
▪ Flask-shaped dilation with obstruction at fimbriae o Marked enhancement of walls/septa of adnexal
o Nonobstructive tubal changes masses with inner wall serration/nodularity
▪ Tufted appearance of ampulla due to surrounding o Avidly enhancing, thickened endometrium ± fluid
diverticular cavities o Peripheral lymph node enhancement most common
▪ Multiple FT constrictions: Beaded appearance ▪ Highly vascular perinodal inflammatory response 6
23
Obgyne Books Full
Fallopian Tubes GENITAL TUBERCULOSIS
▪ Homogeneous, heterogeneous or no nodal o Abnormal bleeding is most common symptom in

enhancement less common postmenopausal women
o Up to 11% of patients asymptomatic
• Grayscale ultrasound • Clinical profile
o Laboratory findings: Leukocytosis, positive
o Dilated FT with thickened wall, containing simple or
tuberculin test, elevated ESR
echogenic fluid o CA125 may be significantly elevated due to
o Mixed echogenicity solid or complex cystic adnexal
peritoneal inflammation
masses
o Endometrial thickening ± fluid (anechoic to Demographics
echogenic) • Age
▪ Synechiae: Echogenic bands traversing cavity o Developing countries: 26–35 years most common
o Peritoneal/omental/mesenteric disease o Developed countries: > 40 years most common
▪ Hypoechoic nodules/masses
o Lymphadenopathy typically hypoechoic, with
• Epidemiology
o 5-15% of patients with pulmonary TB
echogenic centers due to caseation necrosis o Frequent and important cause of chronic PID and
Imaging Recommendations infertility in developing countries
o Rare disease in developed countries, incidence on the
• Best imaging tool rise due to ↑ HIV and immigration
o HSG is best modality for evaluating FT patency and
t
ne
morphology Natural History & Prognosis
o CT is optimal for showing peritoneal, omental, • Poor rate of successful pregnancy after treatment
mesenteric, and nodal disease o 28.6% success rate with in vitro fertilization
o Transvaginal ultrasound and MR are best for
•
e.
Increased risk of ectopic pregnancy
characterizing adnexal masses
Treatment
• Excellent response to multidrug regimen
yn
• Surgery for fistulae and large tubo-ovarian abscesses
PID/Actinomycosis • Total abdominal hysterectomy and bilateral salpingo-
• No significant lymphadenopathy, peritoneal
bg oophorectomy
involvement, or calcification o Indicated with persistent disease
• History of longstanding IUD use in patients with pelvic
ko
actinomycosis
Ovarian Carcinoma
• Tubal pathology not a predominant feature Consider
• Consider TB in setting of bilateral complex cystic
oo
• Coarse calcification typically absent adnexal masses with obliteration of pelvic fat planes,
• Inflammatory changes not present lymphadenopathy, and peritoneal disease
eb

PATHOLOGY • Beading of FT ± calcification
General Features
://
• Etiology SELECTED REFERENCES

o Hematogenous spread from primary TB site
1. Sharma JB et al: Magnetic resonance imaging findings
tp
Gross Pathologic & Surgical Features among women with tubercular tubo-ovarian masses. Int J
• Miliary tubercles on the serosal surface Gynaecol Obstet. 113(1):76-80, 2011
ht
• Rarely Fitz–Hugh–Curtis syndrome (perihepatitis with

2. De Backer A et al: Female genital tract tuberculosis with
peritoneal involvement: CT and MR imaging features. Eur
violin-string adhesions) Radiol Extra. 53(2):71-5, 2005
3. De Backer AI et al: Abdominal tuberculous
• Tubercle formation in tubal wall and mucosa
lymphadenopathy: MRI features. Eur Radiol. 15(10):2104-9,
2005
o Granulomas composed of epithelioid histiocytes ± 4. Hassoun A et al: Female genital tuberculosis: uncommon
Langhans giant cells presentation of tuberculosis in the United States. Am J Med.
• Caseation in advanced cases, followed by fibrosis in
5.
118(11):1295-6, 2005
Matos MJ et al: Genitourinary tuberculosis. Eur J Radiol.
later stages
55(2):181-7, 2005
6. Chavhan GB et al: Female genital tuberculosis:
CLINICAL ISSUES hysterosalpingographic appearances. Br J Radiol.
77(914):164-9, 2004
Presentation 7. Kim SH et al: Unusual causes of tubo-ovarian abscess: CT
• Most common signs/symptoms and MR imaging findings. Radiographics. 24(6):1575-89,
o Infertility 2004
•
8. Vanhoenacker FM et al: Imaging of gastrointestinal and
Other signs/symptoms abdominal tuberculosis. Eur Radiol. 14 Suppl 3:E103-15,
o Pelvic pain, fever, dysmenorrhea, dyspareunia
6 2004
24
Obgyne Books Full
GENITAL TUBERCULOSIS
Fallopian Tubes
extensive pelvic inflammation
with a complex cystic mass
surrounding the uterus
posteriorly. The proximity of the
mass to the right iliac vessels
suggests invasion into the
extraperitoneal space, which
is a characteristic of pelvic
inflammatory disease caused by
tuberculosis. (Right) Axial CECT
in the same patient shows some
components of the inflammatory
mass are tubular, compatible
with dilated inflamed fallopian
tube. Salpingitis is almost
t
always an element of genital
ne
tuberculosis and is typically
bilateral.
e.
yn
bilateral, predominantly solid
adnexal masses . Tubo-ovarian
bg abscesses of tuberculosis may be
cystic, solid, or a combination.
same patient shows that the
ko
left fallopian tube is dilated

with thick enhancing wall.
Obliteration of surrounding fat
oo
planes is further evidence of

active inflammation.
eb
://
tp
ht

peritoneal thickening and
nodularity , a characteristic
of pelvic inflammatory disease
due to tuberculosis. Peritoneal
involvement and associated
elevation of CA125 can make
differentiation from ovarian
malignancy difficult. (Right)
patient shows inflammatory
stranding of the pelvic fat and
reactive wall thickening of the
urinary bladder. The presence of
pelvic inflammation favors genital
tuberculosis and is typically
absent with ovarian malignancy.
6
25
Obgyne Books Full
Fallopian Tubes ACTINOMYCOSIS
Key Facts
Terminology • Tuberculous PID
• Chronic suppurative infection by Actinomyces israelii • Pelvic abscess from other cause
Imaging Pathology
• Infiltrative solid or predominantly solid adnexal mass • Local breakdown of tissue/mucosal barrier (as in IUD
with linear extensions that cross tissue planes use) necessary for infection
• Tiny abscesses in solid components • Infection spreads irrespective of anatomic barriers due
• Presence of intrauterine device (IUD) is typical to organism's proteolytic enzymes
• Colonies macroscopically described as "sulfur granules"
• Commonly involves adjacent structures • Characterized by extensive fibrosis and granulation
o Ureteral invasion with hydronephrosis/hydroureter
o Rectosigmoid colon wall thickening tissue with multiple abscesses, fistulas and sinus tract
• Regional adenopathy uncommon
formation
• Minimal or absent ascites Clinical Issues

• May form masses in cul-de-sac or perirectal space • Abdominal pain, weight loss, vaginal discharge, and
fever
Top Differential Diagnoses • IUD in place for > 3 years, average: 8 years
• Ovarian malignancy • Most common in 4th decade
t
• Pyogenic tubo-ovarian abscess
ne
e.
yn
predominantly solid infiltrative
mass in the pelvis invading
the anterior abdominal wall
bg
. An IUD is noted in
the uterus. Normal ovaries
could not be identified. (Right)
ko
patient shows the mass
invading the transverse colon
resulting in eccentric colon
oo
wall thickening .
eb
://
tp
ht

solid and cystic left adnexal
mass in a patient with an
8-year history of IUD use.
Normal ovaries could not
be identified. IUD had been
recently removed from the
uterus and a drain placed
in the pelvis at the time of
imaging. (Right) Coronal
shows small rim-enhancing
hypodensities within the mass
, and its invasive nature as
it encases the left common
iliac artery . The uterus
and small bowel dilation is
noted.
6
26
Obgyne Books Full
ACTINOMYCOSIS
Fallopian Tubes
o Low to intermediate signal intensity adnexal mass/
TERMINOLOGY
pseudotumoral inflammatory changes
• Chronic suppurative infection by Actinomyces israelii o Adnexal mass
▪ Hypointense and predominantly hypointense
▪ Small hyperintense foci in solid portions
IMAGING correspond to microabscesses
General Features o Solid thick linear extensions
▪ Hypointense
• Best diagnostic clue ▪ Extend from mass to invade adjacent tissue planes
o Adnexal mass
▪ Solid or predominantly solid with avid • T1WI C+
o Avidly enhancing predominantly solid adnexal mass
enhancement
▪ Infiltrative with linear extensions across tissue ▪ Rim enhancement of small hypointense foci
planes (microabscesses)
o Intense enhancement of linear extensions
▪ Tiny internal abscesses
o Surrounding pelvic inflammatory change
▪ Thick-walled cystic mass is less common
o Presence of intrauterine device (IUD) is typical o Enhancement of affected pelvic organs/structures
o Commonly involves adjacent structures (bowel, bladder, ureter)
▪ Ureteral invasion with hydronephrosis/
t
ne
hydroureter
▪ Rectosigmoid colon and, less commonly, other o Predominantly solid adnexal mass with small
bowel segments may be involved internal cystic areas (microabscesses)
– Concentric > eccentric wall thickening
e.
o Less commonly thick-walled cystic adnexal mass
– Mural invasion with stricture formation o Hydronephrosis/hydroureter indicative of ureteral
– Mass effect with luminal narrowing
involvement
yn
– Mucosal fold thickening o Hyperechoic pelvic fat consistent with inflammation
– Perianal fistula formation
o Invasive nature due to proteolytic enzymes Imaging Recommendations
▪ Spread by direct extension across tissue planes
bg
▪ Forms abscesses, fistulas, and sinus tracts o Transvaginal ultrasound (TVUS): First-line modality
o Tendency toward forming granulation tissue and to assess overall morphology of pelvic organs
o CT for better depiction of disease extent, associated
ko
fibrosis
o Regional adenopathy uncommon pelvic inflammatory changes, sinus tracts/fistulae
▪ Does not spread via lymphatics due to size of o MR best modality to confirm invasive nature of
oo
bacteria disease, delineate extent, demonstrate inflammatory

o Minimal or absent ascites component and microabscesses
o Process tends to be confined by regional • Protocol advice
inflammation, thus preventing widespread o Contrast administration improves diagnostic
eb
involvement of peritoneal cavity accuracy of CT and MR imaging

• Location o Core needle biopsy/aspiration can be performed
o 63% cervicofacial under TVUS or CT guidance
://
o 22% abdominal
o 15% thoracic
o Pelvic disease is typically due to ascending genital DIFFERENTIAL DIAGNOSIS
tp
tract infection Ovarian Malignancy

• Pelvic inflammatory changes absent
ht
CT Findings
• CECT • Ascites and lymphadenopathy present in advanced
o Enhancing adnexal mass disease
▪ Solid or predominantly solid • Higher signal intensity of ovarian mass on T2WI
▪ Avid enhancement of solid components
Pyogenic Tubo-Ovarian Abscess
▪ Internal hypodense foci with rim enhancement
(microabscesses) • Adnexal mass is complex, but predominantly cystic
with thick walls
▪ Predominantly cystic mass is less common
presentation • Tissue planes are largely preserved
o Typically has infiltrative borders with thick, linear, Tuberculous PID
intensely enhancing extensions
▪ Extend from mass with invasion and obliteration
• Lymphadenopathy ± calcification
of adjacent tissue planes
• Peritoneal involvement
o Inflammatory changes of adjacent pelvic fat Pelvic Abscess From Other Cause
o May form masses in cul-de-sac or perirectal space • Etiologies include diverticulitis, Crohn disease,
appendicitis
MR Findings
• T1WI • Complex mass, but more cystic with thick walls
• Less invasive, lacks thick linear extensions 6
27
Obgyne Books Full
Fallopian Tubes ACTINOMYCOSIS
• Presence of gas more common o Increasing incidence in past 2 decades

PATHOLOGY • Diagnosis frequently not considered preoperatively
o May lead to unnecessary total abdominal
General Features
• Etiology
hysterectomy (TAH) and bilateral salpingo-
oophorectomy (BSO) for presumed ovarian cancer
o Saprophytic genus in the order Actinomycetales,
mainly A. israelii
• Surgery for undiagnosed cases complicated by multiple
draining fistulae with "sulfur granule" discharge
▪ Fastidious, slow-growing, anaerobic, gram-positive,
filamentous bacterium Treatment
▪ Saprophytic organism, part of normal oral, • Removal of IUD
intestinal and female genital flora • Long-term (up to 1 year) high-dose penicillin ±
• Chronic, suppurative, granulomatous disease percutaneous or surgical drainage
o Characterized by extensive fibrosis and granulation • Secondary surgery for residual abscesses, sinuses, or
tissue with multiple abscesses, fistulas, and sinus strictures
tract formation
• Colonies macroscopically described as "sulfur granules" DIAGNOSTIC CHECKLIST
• Pathogenesis
t
o Colonization of vagina secondary to anal Image Interpretation Pearls
• Predominantly solid tubo-ovarian complex
ne
contamination and urogenital contact
o Local breakdown of tissue/mucosal barrier (as in IUD inflammatory mass containing microabscesses
use) necessary for infection • Extension across tissue planes with sinus tract and
▪ Unable to cross intact mucous membranes due to
e.
fistula formation
low virulence • Presence of an IUD
o Once established, infection spreads irrespective
yn
of anatomic barriers due to organism's proteolytic
SELECTED REFERENCES
enzymes
o Eradication of colonization by removal of IUD or 1. Bae JH et al: Computed tomography for the preoperative
bg diagnosis of pelvic actinomycosis. J Obstet Gynaecol Res.
replacement by copper device
37(4):300-4, 2011
Gross Pathologic & Surgical Features 2. Pusiol T et al: Abdominal-pelvic actinomycosis mimicking
• Actinomycotic "sulfur granules" presenting as yellow malignant neoplasm. Infect Dis Obstet Gynecol.
ko
material in fistulous discharge 2011:747059, 2011
• Infiltrated, indurated pelvis at laparotomy mimicking 3. Rezvani M et al: Fallopian tube disease in the nonpregnant
malignancy
oo
4. Choi MH et al: Pelvic actinomycosis confirmed after

Microscopic Features surgery: single center experience. Arch Gynecol Obstet.
• Identification of actinomycotic "sulfur granules" 281(4):651-6, 2010
• Clumps of actinomycetes on Pap smear: "Gupta bodies"

5. Joshi C et al: Pelvic actinomycosis: a rare entity presenting
eb
as tubo-ovarian abscess. Arch Gynecol Obstet. 281(2):305-6,

• Diagnosis by direct immunofluorescence or anaerobic 2010
culture 6. Baird AS: Pelvic actinomycosis: still a cause for concern. J
://
Fam Plann Reprod Health Care. 31(1):73-4, 2005

7. Kim SH et al: Unusual causes of tubo-ovarian abscess: CT
CLINICAL ISSUES and MR imaging findings. Radiographics. 24(6):1575-89,
tp
2004
Presentation 8. Alfuhaid T et al: Pelvic actinomycosis associated with
• Most common signs/symptoms intrauterine device use: case report. Can Assoc Radiol J.
ht
o Abdominal pain, weight loss, vaginal discharge, and 54(3):160-2, 2003

9. Lee IJ et al: Abdominopelvic actinomycosis involving the
fever
gastrointestinal tract: CT features. Radiology. 220(1):76-80,
2001
o Pelvic mass without signs/symptoms of 10. Hawnaur JM et al: Magnetic resonance imaging of
inflammation, even in the presence of established actinomycosis presenting as pelvic malignancy. Br J Radiol.
infection 72(862):1006-11, 1999
• Clinical profile 11. Müller-Holzner E et al: IUD-associated pelvic actinomycosis:
o IUD in place for > 3 years, average: 8 years a report of five cases. Int J Gynecol Pathol. 14(1):70-4, 1995
• Laboratory findings
o Anemia, leukocytosis, elevated ESR
o CA125 typically normal or only mildly elevated
Demographics
• Age
o Most common in 4th decade
• Epidemiology
o Present in vaginal cultures in as many as 27% of
6 women without IUD
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Obgyne Books Full
ACTINOMYCOSIS
Fallopian Tubes
(Left) Longitudinal
shows a solid mass between
the uterus and urinary
bladder. The mass is invading
the bladder dome . (Right)
ultrasound with color Doppler
shows internal blood flow
within the solid mass interposed
between the uterus and the
urinary bladder. Note invasion
of the mass into the bladder
lumen.
t
ne
e.
yn
same patient confirms the
predominantly solid nature
bg of the avidly enhancing mass
. There is inflammation of
the pelvic fat with surrounding
increased density and fluid. No
ko
normal ovary could be identified

in this patient with a 3-year
history of IUD use. (Right) Axial
oo

thick linear enhancement
extending from the mass and
invading the anterior abdominal
eb
wall. The IUD had been removed

from the uterus by the time of
imaging.
://
tp
ht

the intensely enhancing solid
mass invading the dome of
the urinary bladder with
disruption of the normal low-
signal bladder wall . (Right)
same patient at the midline
shows the mass invading the
anterior abdominal wall .
6
29
Obgyne Books Full
Fallopian Tubes SALPINGITIS ISTHMICA NODOSA
Key Facts
Imaging Pathology
• Multiple small diverticula extending from lumen of • Unknown, may be postinflammatory &/or
fallopian tube into wall adenomyosis-like process
• Most often occurs in isthmus and intramural segments • Many patients have history of pelvic inflammatory
• Bilateral in 60-80% of cases disease but does not explain all cases
o Presence of SIN may increase susceptibility to
o Tubes may be asymmetrically affected
• Often associated with proximal obstruction or developing an infection
hydrosalpinx • ~ 50% of tubes removed for ectopic pregnancy have
• Conventional (fluoroscopic) HSG study of choice SIN
o Avoid lymphatic or venous intravasation as may be • Mucosal irritation from chlamydia infection may cause
mistaken for free spill muscular hypertrophy of tube
• MR may show small cysts clustered around intramural Clinical Issues
portion of tube
• Patients are at risk for recurrent ectopic pregnancy
Top Differential Diagnoses • High association with infertility
• Tubal endometriosis • Now, with in vitro fertilization and embryo transfer,
• Tuberculosis tubal repair has fallen out of favor
t
ne
e.
yn
(Left) Coronal graphic shows
multiple diverticula
involving the intramural
and isthmic portions of the
bg
fallopian tube, with areas
of nodular hyperplasia of
the surrounding muscle .
ko
(Right) A spot view of the right
fallopian tube shows small
diverticula throughout the
the isthmic portion of the tube,
oo
typical of SIN.
eb
://
tp
ht
(Left) This patient presented

with an ectopic pregnancy
adjacent to the left ovary
(LO). This was her 3rd tubal
ectopic, all of which were
treated with methotrexate.
(Right) Hysterosalpingography
(same patient) was ordered
as part of her work-up.
Severe bilateral proximal
fallopian tube diverticula
are seen. Approximately
50% of tubes removed for
ectopic pregnancy have SIN.
Underlying SIN should be
considered in a patient with
recurrent ectopic pregnancies.
6
30
Obgyne Books Full
SALPINGITIS ISTHMICA NODOSA
Fallopian Tubes
TERMINOLOGY • Protocol advice
o Continuous gentle pressure may be needed to fill
Abbreviations diverticula
• Salpingitis isthmica nodosa (SIN) ▪ Stop if venous or lymphatic intravasation seen
– May be mistaken for free spill
Synonyms o Fallopian tube catheterization has increased ability to
• Tubal diverticulosis diagnose SIN
• Tubal adenomyosis ▪ Ability to fill isthmic diverticula beyond
Definitions proximally occluded tube
o Magnified spot films are useful
• Small outpouchings or diverticula from isthmic
portion of fallopian tube
IMAGING Tubal Endometriosis
General Features • 6% of patients with endometriosis have tubal implants
• Best diagnostic clue • Occurs in 2 forms
o Small diverticula in proximal 2/3 of fallopian tube o Serosal implants
▪ Causes scarring with tubal distortion
• Location
▪ Hydrosalpinx
t
o Bilateral in 60-80% of cases
o Endoluminal
ne
o Tubes may be asymmetrically affected
▪ Hematosalpinx most common finding
• Size
– Bright on both T1 and T2; does not cause T2
o Typically outpouchings are 2 mm in diameter and
e.
shading as in endometriomas
clustered over tubal length of 1-2 cm ▪ May cause nodular irregularity but not diverticula
Hysterosalpingography (HSG) Tuberculosis
yn
• Multiple small diverticula extending from lumen of • May cause isthmic diverticulosis identical to SIN
fallopian tube into wall
• Most often occurs in isthmus and intramural segments, • Tuberculous peritonitis present in 50% of cases
o Loculated ascites
bg
less often in ampullary segment
o Peritoneal thickening with omental/mesentery soft
• Additional findings as severity increases tissue infiltration
o Tubal lumen becomes narrowed and irregular
o Enlarged low-attenuation (necrotic) lymph nodes
ko
o Proximal obstruction
o Hydrosalpinx • May have tubal calcifications in chronic disease
o Extraluminal channels frequently seen Salpingitis
• Tubal thickening ± hydrosalpinx
oo
o Large irregular diverticula

• SIN is found in 50% of patients on post tubal
• Diagnosis is made histologically
recanalization HSG o Fibrosis and fusion of plicae
eb
MR Findings o Lymphoplasmacytic infiltrate in lamina propria

• Best for intramural segment of tube • Sequelae of prior pelvic inflammatory disease
o Small cysts clustered around course of tube through
Uterine Adenomyosis
://
•
myometrial wall
Difficult to see in remainder of tube unless very • Thickened junctional zone with small cystic spaces
o Best seen on T2WI
tp
•
thickened
o Small nodules of hypertrophic muscle More diffuse, not just clustered around intramural
• Hydrosalpinx generally follows fluid signal (low on
•
portion of tube
ht
SIN of intramural portion of tube may be a similar

T1WI and high on T2WI)
o Can have subtle increased signal on T1WI depending pathologic process to diffuse uterine adenomyosis
on protein content
• MR HSG is an emerging technology for infertility PATHOLOGY
evaluation
General Features
Ultrasonographic Findings • Etiology
• Sonohysterosalpingography useful for tubal patentcy o Unknown; may be postinflammatory &/or
but not morphology adenomyosis-like process
o May see thickened tube but cystic changes usually o Many patients have history of pelvic inflammatory
not demonstrated disease but does not explain all cases
▪ 3D US may prove helpful in future ▪ Chlamydia trachomatis most common pathogen
o Does not show anatomy of tube as well as
cultured
conventional HSG ▪ Presence of SIN may increase susceptibility to
Imaging Recommendations developing an infection
o May be analogous to uterine adenomyosis
o HSG
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Fallopian Tubes SALPINGITIS ISTHMICA NODOSA
Staging, Grading, & Classification o Incidence of posttreatment ectopic pregnancy:

• Classification of proximal tubal occlusion 4.5-10%
o Nodular • Now, with advanced reproductive technologies, tubal
▪ SIN repair has fallen out of favor
o In vitro fertilization and embryo transfer now
▪ Endometriosis
o Nonnodular considered treatment of choice
▪ True fibrotic occlusion
o Pseudo-occlusion DIAGNOSTIC CHECKLIST
▪ Detritus
▪ Polyps Consider
▪ Hypoplastic tubes • SIN should be considered in patient with recurrent
ectopic pregnancies
• Discrete nodular swelling in proximal portion of tube Image Interpretation Pearls
o Superficial adhesions can be observed on laparoscopy • Often associated with tubal occlusion or hydrosalpinx
o Nodular tissue firm to touch • Do not mistake lymphatic or venous intravasation for
free spill
• Nodular thickening of proximal fallopian tube SELECTED REFERENCES
t
enclosing cystically dilated glands trapped in a
ne
muscular layer 1. Luciano DE et al: Contrast Ultrasonography for Tubal
o Nodular thickening may lead to complete tubal Patency. J Minim Invasive Gynecol. Epub ahead of print,
occlusion 2014
•
e.
SIN may coexist with chronic salpingitis but unclear 2. Panchal S et al: Imaging techniques for assessment of tubal
relationship between them status. J Hum Reprod Sci. 7(1):2-12, 2014
o Antibodies to Chlamydia usually present 3. Maheux-Lacroix S et al: Hysterosalpingosonography
yn
for diagnosing tubal occlusion in subfertile women: a
▪ Mucosal irritation from Chlamydia infection may
systematic review protocol. Syst Rev. 2:50, 2013
cause muscular hypertrophy of tube 4. Yaranal PJ et al: Salpingitis isthmica nodosa: a case report. J
Clin Diagn Res. 7(11):2581-2, 2013
bg
5. Ma L et al: Fallopian tubal patency diagnosed by magnetic
CLINICAL ISSUES resonance hysterosalpingography. J Reprod Med.
Presentation 57(9-10):435-40, 2012

ko
6. Schippert C et al: The risk of ectopic pregnancy
following tubal reconstructive microsurgery and assisted
o Infertility reproductive technology procedures. Arch Gynecol Obstet.
o Ectopic pregnancy 285(3):863-71, 2012
•
oo
Other signs/symptoms 7. Rezvani M et al: Fallopian tube disease in the nonpregnant

o May have prior history of PID patient. Radiographics. 31(2):527-48, 2011
8. Allahbadia GN et al: Fallopian tube recanalization: lessons
Demographics learnt and future challenges. Womens Health (Lond Engl).
eb
• Age 6(4):531-48, quiz 548-9, 2010

o Develops during reproductive years 9. Chawla N et al: Salpingitis isthmica nodosa. Indian J Pathol
Microbiol. 52(3):434-5, 2009
▪ Mean age at diagnosis: 30 years
://
•
10. Steinkeler JA et al: Female infertility: a systematic approach
Epidemiology to radiologic imaging and diagnosis. Radiographics.
o Prevalence in healthy, fertile women = 0.6-11% 29(5):1353-70, 2009
tp
o More common in setting of ectopic pregnancy and 11. Simpson WL Jr et al: Hysterosalpingography: a reemerging
infertility study. Radiographics. 26(2):419-31, 2006
o Common cause of proximal tubal disease 12. Almeida OD Jr: Microlaparoscopy and a GnRH agonist: a
ht
▪ 23-60% in histologically documented cases combined minimally invasive approach for the diagnosis
and treatment of occlusive salpingitis isthmica nodosa
Natural History & Prognosis associated with endometriosis. JSLS. 9(4):431-3, 2005
• Patients are at risk for recurrent ectopic pregnancy 13. Awartani K et al: Microsurgical resection of nonocclusive
salpingitis isthmica nodosa is beneficial. Fertil Steril.
o ~ 50% of tubes remove for ectopic pregnancy have
79(5):1199-203, 2003
SIN 14. Houston JG et al: Salpingitis isthmica nodosa: technical
▪ Compares to 5% in control population success and outcome of fluoroscopic transcervical fallopian
tube recanalization. Cardiovasc Intervent Radiol. 21(1):31-5,
Treatment 1998
• Microsurgical approaches 15. Thurmond AS et al: Salpingitis isthmica nodosa: results of
o Microsurgical resection and tubocornual anastomosis transcervical fluoroscopic catheter recanalization. Fertil
of nonocclusive SIN Steril. 63(4):715-22, 1995
▪ Postsurgical studies have described intrauterine 16. Gurgan T et al: Salpingoscopic findings in women with
occlusive and nonocclusive salpingitis isthmica nodosa.
pregnancy rates of 46-56%
Fertil Steril. 61(3):461-3, 1994
o Also may reduce risk for ectopic pregnancy
▪ Postsurgical ectopic rate: 11%
• Fluoroscopic transcervical fallopian tube recanalization
6 o Post-treatment intrauterine pregnancy rate: 23-30%
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SALPINGITIS ISTHMICA NODOSA
Fallopian Tubes
(Left) Image from a
hysterosalpingogram shows
multiple tiny diverticula
in the isthmus of the right
fallopian tube associated with
mid tubal obstruction and
lymphatic intravasation .
(Right) A more delayed image in
same patient with SIN and
mid tubal obstruction shows
prominent venous intravasation
. Intravasation results from
continued applied pressure to
an occluded system. This should
be recognized and not confused
with free spill.
t
ne
e.
yn
(Left) HSG spot film of the right
fallopian tube shows SIN of
the isthmic portion of the tube
bg and a hydrosalpinx . Tubal
obstruction, either proximal or
a hydrosalpinx, is a common
associated finding with SIN
ko
and is one cause of infertility.

(Right) H&E stain of a cross
section of a fallopian tube shows
oo
and narrowed tubal lumen

surrounded by a thick muscular
wall with cystically dilated glands
. (From DP: GYN.)
eb
://
tp
ht
(Left) When SIN is severe,

diverticula may become
confluent and extraluminal
channels can develop. (Right)
T2WI MR, rotated to show a long
axis view through the uterus,
shows bilateral cystic spaces
surrounding the intramural
portions of both fallopian tubes.
The appearance overlaps with
adenomyosis. Histologically,
there is also overlap, and SIN has
been called tubal adenomyosis
by some pathologists. It is
important to raise the diagnosis
of SIN when cysts are limited
to the cornua, especially in a
woman with fertility issues.
(Courtesy A. Thurmond, MD.)
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Fallopian Tubes TUBAL LEIOMYOMA
Key Facts
• Benign smooth muscle tumor arising from muscular • Subserosal uterine leiomyoma
layer of fallopian tube • Ovarian leiomyoma/fibroma
Imaging • Tubal adenocarcinoma
• Sausage-shaped solid adnexal mass Clinical Issues
• Separate from uterus and ovary • Pre- and postmenopausal women
• Solitary • Usually asymptomatic
• Unilateral • Typically incidentally found at autopsy or unrelated
• Left more common than right surgical procedure
• T1: Isointense to myometrium • Patients can present with acute abdomen if they
• T2: Circumscribed, fusiform mass hypointense to develop a complication
myometrium • Complications: Torsion, degeneration, ectopic
• Rim sign on MR helps suggest tubal origin pregnancy, tubal obstruction
• US: Homogeneous, hypoechoic, fusiform solid mass
with poor sound transmission
t
ne
e.
yn
(Left) Transabdominal
ultrasound shows a solid,
hypoechoic, fusiform mass
bg
ko
the circumscribed mass in
the cul-de-sac.
oo
eb
://
tp
ht
(Left) Axial CECT more

superiorly shows a normal
and separate right ovary
. Also note the uterus
and left ovary . (Right)
Axial T2WI FSE MR at the
level of the cervix shows
homogeneous hypointensity
of the fusiform, circumscribed
adnexal mass shown on
other images to be separate
from the ovaries and uterus.
Signal characteristics and
morphology are consistent
with a fallopian tube
leiomyoma.
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TUBAL LEIOMYOMA
Fallopian Tubes
o Most often homogeneous
TERMINOLOGY o May be of mixed echogenicity
Synonyms • Pulsed Doppler
• Tubal fibroid o Low impedance flow
Definitions Imaging Recommendations

• Benign smooth muscle tumor arising from muscular • Best imaging tool
layer of fallopian tube o MR is diagnostic modality of choice
▪ Characterizes mass as leiomyoma
▪ Localizes mass to fallopian tube
IMAGING
• Protocol advice
General Features o High-resolution FSE T2WI
• Best diagnostic clue ▪ Typically obtained in coronal oblique (short axis
o Sausage-shaped solid adnexal mass of uterus) and axial oblique (long axis of uterus)
o Separate from uterus and ovary planes
▪ Absent claw sign with uterus/ovary ▪ Demonstrates characteristic very low signal
▪ Absent bridging vessel sign with myometrium intensity of fibrous tumor
• Location ▪ Oriented along short and long axis of uterus to
o Ampullary-isthmic junction demonstrate absence of connection to uterus
t
o Unilateral ▪ Allows identification of normal ovaries, confirms
ne
o Left more common than right mass is separate from ovaries
▪ Can orient along long axis of mass to show
• Size
"sausage" shape
o Typically small, < 3 cm
e.
o T1 C+ FS
• Morphology
▪ May help identify tubal origin by demonstrating
o Most commonly homogeneous
enhancing tubal wall surrounding mass
yn
o Pedunculated or broad-based
o Solitary
o Degeneration is less common than uterine DIFFERENTIAL DIAGNOSIS
leiomyomas, possibly due to smaller size
bg
Subserosal Uterine Leiomyoma
CT Findings • Signal intensity mimics fallopian tube leiomyoma
• CECT • Often larger
ko
o Sausage-shaped juxtauterine mass extending toward

• Usually multiple
but separate from ovary
o Variable enhancement • Vascular pedicle connecting mass to uterus
o Bridging vessel sign
oo
MR Findings Ovarian Leiomyoma/Fibroma

• T1WI • Signal intensity mimics FT leiomyoma
o Fusiform mass
• Mass draped by ovarian tissue, claw sign
eb
o Isointense to myometrium
o May be hyperintense if has hemorrhagic • No cleavage plane with ovary
degeneration • Move together with transvaginal transducer pressure
://
• T2WI Tubal Adenocarcinoma

o Circumscribed, fusiform mass
• Usually, complex hydrosalpinx with enhancing mural
tp
o Hypointense to myometrium nodules/papillary projections

o Foci of hyperintensity if cystic degeneration present
▪ Uncommon due to typical small size
• Malignant fallopian tube tumors more common than
ht
benign tumors
o Tubal origin may be seen in some cases
▪ Intermediate to low signal rim surrounds portion Other Mesodermal Tubal Tumors
or entire circumference of mass • Fibroma, lipoma, hemangioma, mesothelioma,
o Separate ovary usually best identified on T2WI lymphangioma, fibroadenoma, papilloma, mucosal
• T1WI C+ FS polyp, adenomatoid tumor
o Variable enhancement
▪ Hypovascular or isovascular to myometrium PATHOLOGY
o Tubal origin may be seen in some cases
▪ Hypervascular rim surrounds portion or entire General Features
circumference of mass • Etiology
o Derived from müllerian ducts as are uterine
• Grayscale ultrasound leiomyomas
▪ Unlike uterine leiomyomas, do not arise on
o Hypoechoic fusiform solid mass
background of muscularis propria hypertrophy
o Distinct from uterus and ovary o Theorized to be less common than uterine
▪ Moves separately from uterus/ovary on
leiomyomas due to lack of fallopian tube response to
o Poor sound transmission
hormonal stimulation/changes
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Fallopian Tubes TUBAL LEIOMYOMA
• Associated abnormalities Natural History & Prognosis

o Uterine leiomyomas • Usually asymptomatic and incidentally found at
Gross Pathologic & Surgical Features autopsy or unrelated surgical procedure
• Fusiform swelling of tubal wall with dome-like • Complications
o Excessive growth
projection in compressed lumen
o Torsion
• Well-circumscribed, unencapsulated o Degenerative
• Pedunculated mass o Purulent changes
• Ovoid mass o Ectopic pregnancy
• Smooth mass • No report of malignant transformation
• Firm mass
• Solitary Treatment
• Small • Tubal sparing surgery when possible
• Whorled cut surface • Salpingectomy when diagnosis uncertain or in
• Unilateral, left > right complicated cases
• Confirmation of tubal patency after tumor resection
• Elongated smooth muscle elements arranged in DIAGNOSTIC CHECKLIST
interweaving, intersecting bundles and fascicles
t
• Positivity for alpha smooth muscle actin on
ne
immunohistochemistry • Sausage-shaped solid adnexal mass
• Continuity with tubal muscularis layer • Distinct from uterus and ovary
• Histologic features o No claw sign
e.
o Intersecting fascicles of spindle cells o No bridging vessels sign
o Variable collagen deposition
• Imaging characteristics of uterine leiomyoma
yn
o Nuclear palisading may be seen
o Variable numbers of mast cells • Rim sign on MR helps suggest tubal origin
o Prominent large, thick blood vessels
• Cytologic features
bg SELECTED REFERENCES
o Spindled cells with eosinophilic cytoplasm 1. Oliva E: Leiomyoma and variants. In Nucci M et al:
o Epithelioid cells with eosinophilic or clear cytoplasm Diagnostic Pathology: Gynecological. 1st ed. Salt Lake City:
o Rhabdoid cells with abundant eosinophilic
ko
Amirsys, 2014
cytoplasm with rounded/globoid appearance 2. Rezvani M et al: Fallopian tube disease in the nonpregnant
o Mild cytologic atypia if any patient. Radiographics. 31(2):527-48, 2011
o Variable mitotic activity 3. Yang CC et al: Primary leiomyoma of the fallopian tube:
oo
preoperative ultrasound findings. J Chin Med Assoc.

▪ Usually low, can be up to 15/10 HPF
70(2):80-3, 2007
▪ Increased mitotic activity around areas of 4. Berzal-Cantalejo F et al: Solitary fibrous tumor arising in the
infarction
eb
fallopian tube. Gynecol Oncol. 96(3):880-2, 2005

5. Wen KC et al: Primary fallopian tube leiomyoma managed
by laparoscopy. J Minim Invasive Gynecol. 12(3):193, 2005
CLINICAL ISSUES 6. Misao R et al: Leiomyoma of the fallopian tube. Gynecol
://
Obstet Invest. 49(4):279-80, 2000

Presentation
7. Mroueh J et al: Tubal pregnancy associated with ampullary
tubal leiomyoma. Obstet Gynecol. 81(5 ( Pt 2)):880-2, 1993
tp
o Asymptomatic 8. Schust D et al: Leiomyomas of the fallopian tube. A case

• Other signs/symptoms report. J Reprod Med. 38(9):741-2, 1993
o Vague pelvic discomfort 9. Escoffery CT et al: Leiomyoma of the fallopian tube: an
ht
o Abdominal pain secondary to obstruction of tubal unusual cause of abdominal pain. Int J Gynaecol Obstet.
38(2):128-9, 1992
lumen 10. Moore OA et al: Leiomyoma of the fallopian tube: a cause of
o Palpable adnexal mass tubal pregnancy. Am J Obstet Gynecol. 134(1):101-2, 1979
o Patient may present with acute abdomen if tubal 11. Crissman JD et al: Leiomyoma of uterine tube: report of a
leiomyoma is complicated by case. Am J Obstet Gynecol. 126(8):1046, 1976
▪ Torsion 12. Honore LH et al: Leiomyoma of the Fallopian tube. A
▪ Ectopic pregnancy case report and review of the literature. Arch Gynakol.
▪ Degeneration 221(1):47-50, 1976
Demographics
• Age
o Pre- and postmenopausal women
• Epidemiology
o Rare entity, much less common than uterine
leiomyomas
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TUBAL LEIOMYOMA
Fallopian Tubes
shows an oval, hypoechoic left
adnexal mass (calipers) with
posterior acoustic shadowing .
normal left ovary (calipers)
containing a few follicles
located adjacent to the left
adnexal mass . Although the
ovary abuts the mass, no claw
of ovarian tissue surrounds the
mass.
t
ne
e.
yn
the oval, circumscribed left
bg adnexal mass with diffuse
internal low signal compatible
with a leiomyoma. The mass
focally abuts the uterus.
ko

FSE MR more clearly shows the
left adnexal mass is separate
oo
from the uterus . Also noted

is a subserosal leiomyoma
arising from the right uterus, as
well as a dominant follicle in
eb
the left ovary.

://
tp
ht

the left adnexal mass is
isointense to myometrium
as would be expected for a
leiomyoma. (Right) Sagittal
patient shows homogeneous
enhancement of the mass
and shows to best advantage
the sausage-shaped morphology.
Although abutting the left ovary
, the mass is confirmed
to be separate. The signal
characteristics and location are
compatible with a viable left
fallopian tube leiomyoma.
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Fallopian Tubes FALLOPIAN TUBE CARCINOMA

(T) Primary Tumor
Tis¹ Carcinoma in situ (limited to tubal mucosa)
T1 I Tumor limited to fallopian tube(s)
T1a IA Tumor limited to 1 tube, without penetrating serosal surface; no ascites
T1b IB Tumor limited to both tubes, without penetrating serosal surface; no ascites
T1c IC Tumor limited to 1 or both tubes with extension into or through tubal serosa, or with
malignant cells in ascites or peritoneal washings
T2 II Tumor involves 1 or both fallopian tubes with pelvic extension
T2a IIA Extension &/or metastasis to uterus &/or ovaries
T2b IIB Extension to other pelvic structures
t
T2c IIC Pelvic extension with malignant cells in ascites or peritoneal washings
ne
T3 III Tumor involves 1 or both fallopian tubes, with peritoneal implants outside pelvis
T3a IIIA Microscopic peritoneal metastasis outside pelvis
Macroscopic peritoneal metastasis outside pelvis ≤ 2 cm in greatest dimension
e.
T3b IIIB
T3c IIIC Peritoneal metastasis > 2 cm in diameter
yn
bg
N1 IIIC Regional lymph node metastasis
ko

oo
M1 IV Distant metastasis
Liver capsule metastasis is T3/stage III; liver parenchymal metastasis is M1/stage IV; pleural effusion must have positive
cytology for M1/stage IV.
eb

://
Stage T N M
tp
0 Tis N0 M0
IA T1a N0 M0
ht
IB T1b N0 M0
IC T1c N0 M0
IIA T2a N0 M0
IIB T2b N0 M0
IIC T2c N0 M0
IIIA T3a N0 M0
IIIB T3b N0 M0
IIIC T3c N0 M0
Any T N1 M0
IV Any T Any N M1
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FALLOPIAN TUBE CARCINOMA
Fallopian Tubes
Tis Tis
t
ne
e.
yn
Low-power magnification of H&E-stained full section of carcinoma High-power magnification of the epithelial cells with carcinoma
in situ and fallopian tube shows the lumen lined by endosalpingeal in situ shows loss of polarity with papillary formation that lack
epithelial cells forming papillae .
bg
stromal cores. Note the cellular atypia of the lining cells and the
mitotic figure . The basement membrane is intact.
T1a (FIGO IA) T1a (FIGO IA)

ko
oo
eb
://
tp
ht
Low-power magnification shows tumor limited to the fallopian tube Intermediate-power magnification depicts a close-up on the sheets
(T1a). H&E stain shows tumor cells within the wall of the fallopian of tumor cells that do not extend to the serosal aspect (inked
tube. The left side clear space represents the luminal aspect of the black, top) of the tube.
fallopian tube with the lining epithelium. The tumor is limited to
the wall of the fallopian tube.
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t
ne
e.
yn
H&E stain from the wall of a fallopian tube demonstrates tumor H&E section of tumor with pelvic extension to the surface of the
invading through the wall of the tube. Note the surface epithelium ovary (T2a) displays tumor nodules visible on the surface of the
on the luminal side .
bg
ovary .
T2a (FIGO IIA) T3 (FIGO III)

ko
oo
eb
://
tp
ht
Intermediate-power magnification shows a tumor nodule on the H&E stain demonstrates peritoneal tumor implants outside the
surface of the ovary. Note the stroma composed of whorls of plump pelvis (T3).
spindle cells of fibroblastic type that is characteristic of the ovary
.
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Fallopian Tubes
T1a (FIGO IA) T1b (FIGO IB)
t
ne
e.
yn
Graphic of the uterus as viewed from above shows T1a disease: Graphic of the uterus as viewed from above shows T1b disease:
Tumor is limited to 1 fallopian tube , without penetrating the Tumor is limited to both fallopian tubes , without penetrating the
serosal surface, and there is no ascites.
bg
serosal surface, and there is no ascites.

ko
oo
eb
://
tp
ht
Two graphics of the uterus as viewed from above show T1c disease: Graphic of the uterus as viewed from above shows T2a disease:
Tumor is limited to 1 or both fallopian tubes, with extension into or Tumor involving 1 or both fallopian tubes , with pelvic extension
through the tubal serosa , shown on the left, and with malignant to the uterus &/or ovaries .
cells in ascites or peritoneal washings on the right.
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T2b (FIGO IIB) T2c (FIGO IIC)
t
ne
e.
yn
Graphic of the uterus as viewed from above shows T2b disease: Graphic of the uterus as viewed from above shows T2c disease:
Tumor involving 1 or both fallopian tubes with extension to pelvic Pelvic extension with malignant cells in ascites or peritoneal
organs other than the uterus and ovaries. Shown here is extension
bg
washings.
to the rectum .
T3a (FIGO IIIA) T3b (FIGO IIIB)

ko
oo
eb
://
tp
ht
T3a tumors involve microscopic peritoneal metastases beyond T3b tumors feature macroscopic peritoneal metastases beyond the
the pelvis. These cannot be visualized by imaging; rather, they are pelvis that are ≤ 2 cm in greatest dimension.
found through peritoneal biopsy at staging laparotomy.
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Fallopian Tubes
T3c (FIGO IIIC) Nodal Drainage of Fallopian Tubes
t
ne
e.
yn
T3c tumors involve macroscopic peritoneal metastases beyond the Fallopian tube lymphatics follow the ovarian veins to the paraaortic
pelvis, larger than 2 cm in greatest dimension. lymph nodes . Lymphatic spread may also occur through the
bg
broad ligament to the pelvic lymph nodes and along the round
ligament to the inguinal lymph nodes .
ko
oo

Liver 20.5%
eb
Pleura 18%
Vagina 15.5%
://
Lung 13%
tp
Bone 2.6%
Brain 2.6%
ht
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▪ Pregnancy and use of oral contraceptives ↓ risk

OVERVIEW significantly
Classification • Epidemiology & cancer incidence
o Least common of gynecological malignancies
• Histological types of primary fallopian tube carcinoma ▪ Accounts for approximately 0.3–1.8% of female
(PFTC) include
o Papillary serous carcinoma (49.5-83.3%) genital malignancies
o Endometrioid (8.3-50%) ▪ Annual incidence is 3.6-4.1 per 1,000,000 women
o Mixed (3.9-16.7%) ▪ True incidence may be underestimated because of
o Clear cell (1.9%) difficulty in differentiating PFTC from epithelial
o Transitional (11.7%) ovarian carcinoma, especially in advanced cases
o In 1 series, 35% of women with PFTC had history of
breast cancer
o Most frequently occurs between 4th and 6th decades
PATHOLOGY of life
Routes of Spread ▪ Median age of occurrence of 55 years (range: 17–88
• Pattern of spread is similar to ovarian carcinoma years)
o Bilateral tumors reported in 10-27% of cases
• Peritoneal spread
o In ~ 80% of patients with advanced disease, • Associated diseases, abnormalities
o CA125 is useful tumor marker for diagnosis,
t
metastases are confined to peritoneal cavity
• Lymphatic spread assessment of response to treatment, and detection of
ne
o Lymphatic drainage of PFTC mirrors that of uterine tumor recurrence during follow-up
▪ > 80% of patients have elevated pretreatment
fundus and ovaries
▪ Along ovarian vessels → paraaortic nodes serum CA125 levels
e.
▪ Pretreatment serum CA125 level is independent
▪ Along broad ligament → pelvic nodes
prognostic factor of disease-free survival and
▪ Along round ligament of uterus → superficial
yn
overall survival
inguinal nodes
o Early lymphatic metastases are common ▪ Lead time (↑ CA125 levels prior to clinical or
radiological diagnosis of recurrence) is 3 months
▪ Incidence of positive nodes is 40–60% when there
bg (range: 0.5–7 months)
is extratubal tumor spread
• Hematogenous spread Gross Pathology & Surgical Features
o Can occur to liver, pleura, vagina, lungs, and brain • Most arise in ampulla and project into tubal lumen,
• Endoluminal spread
ko
often causing occlusion

o Spread to proximal part of fallopian tube and uterus • Pattern of growth can be nodular, papillary, infiltrative,
General Features or massive
oo
• Genetics • Criteria for diagnosis of PFTC

o Main tumor in tube and arises from endosalpinx
o PFTC has been described in high-risk breast–ovarian
o Histological pattern reproduces epithelium of tubal
cancer families with germline BRCA1 and BRCA2
eb
mucosa (papillary pattern)

mutations o If wall is involved, transition from benign to
▪ BRCA mutations were noted in 16% of invasive
malignant tubal epithelium should be demonstrated
PFTC patients o Ovaries and endometrium are normal or have much
▪ Occult PFTC found in 5.6% of BRCA patients who
://
smaller tumor volume than that of tube

underwent prophylactic risk-reducing salpingo-
oophorectomy Microscopic Pathology
tp
▪ 44% of occult malignancies found in prophylactic • H&E

oophorectomy specimens are of tubal origin o Most common histologic type is papillary serous
ht
▪ Increasing evidence that tubal fimbriae may be carcinoma

preferred site of origin of adnexal cancer in carriers ▪ Histologically identical to ovarian serous
of BRCA gene mutations adenocarcinoma
• Etiology ▪ Produces large amount of serous fluid → tubal
o Etiology of PFTC is unknown distension and hydrosalpinx
▪ Hormonal, reproductive, and possibly genetic o Serous tumors show papillary patterns with cords or
factors thought to ↑ risk of epithelial ovarian sheets of pleomorphic cells
tumors might also ↑ PFTC risk
▪ 25-30% of cases in nulliparous women
▪ 5x higher bilateral occurrence in infertile patients IMAGING FINDINGS
than in fertile patients
▪ No statistically significant correlation between Detection
PFTC and age, race, weight, education level, • Ultrasound
pelvic inflammatory disease, infertility, previous o Sonographic appearance of PFTC is nonspecific,
hysterectomy, endometriosis, lactose intolerance, mimicking other pelvic diseases, such as tubo-
or smoking ovarian abscess, ovarian tumor, and ectopic
▪ Better prognosis in nulliparous women
6
pregnancy
▪ High parity may be protective
44
Obgyne Books Full
Fallopian Tubes
o Presence of partially solid/cystic mass separate from o Total abdominal hysterectomy
ovary is highly suggestive of PFTC o Bilateral salpingo-oophorectomy
o Sonographic features include o Omentectomy
▪ Sausage-shaped solid mass o Systematic pelvic and paraaortic nodal dissection
▪ Cystic anechoic tubular structure with mural o Peritoneal and diaphragmatic biopsies
nodules o Cytological evaluation of peritoneal washings
▪ Multilocular mass with "cog and wheel" • CT
appearance o Primary imaging modality for preoperative staging
▪ Color Doppler US: Low impedance vascular flow PFTC
within solid components o In many cases, preoperative diagnosis is that of EOC
• CT o Goals of preoperative imaging, as with EOC, are
o When associated with hydrosalpinx ▪ Recognition of extensive disease that is
▪ Mixed solid cystic adnexal mass or tubular cystic unresectable
structure with papillary projections ▪ Detection of metastatic disease to prevent
▪ Solid components have attenuation equal to that understaging and allow adequate intraoperative
of other soft tissue masses and enhance less than sampling of suspected lesions
myometrium o Factors that generally indicate inoperable disease
o When not associated with hydrosalpinx include
▪ Sausage-shaped solid adnexal mass has attenuation ▪ Invasion of pelvic sidewall, rectum, sigmoid colon,
t
equal to that of other soft tissue masses and or bladder
ne
enhances less than myometrium ▪ Bulky peritoneal disease
o Attempt should be made to identify ovaries separate – Porta hepatis
from adnexal tubal mass – Intersegmental fissure of liver
e.
▪ Ovaries can be identified by following ovarian vein – Lesser sac
&/or round ligament – Gastrosplenic ligament
o Associated findings include – Gastrohepatic ligament
yn
▪ Peritumoral ascites resulting from tubal – Subphrenic space
decompression through fimbrial end – Small bowel mesentery
▪ Intrauterine fluid collection – Supracolic omentum
bg
▪ Peritoneal implants – Presacral space
• MR ▪ Suprarenal and splenic adenopathy
o When associated with hydrosalpinx ▪ Hepatic and splenic (parenchymal), pleural, or
ko
▪ Mixed solid cystic adnexal mass or tubular cystic pulmonary metastases

structure with papillary projections • MR
▪ Cystic component of low signal intensity on T1W o Can be used as alternative to CT for local staging
oo
images and high signal intensity on T2W images

– Cystic component may have high T1 signal Restaging
intensity due to hemorrhage • CT
▪ Solid components show enhancement after o Modality of choice for restaging and detection of
eb
administration of IV gadolinium recurrent disease

o When not associated with hydrosalpinx • PET/CT
▪ Solid adnexal mass with predominantly low signal o Useful in identifying patients with recurrent PFTC
://
intensity on T1WI and high signal intensity on

T2WI
CLINICAL ISSUES
tp
▪ Heterogeneous enhancement after administration

of IV gadolinium
o Change in appearance on serial imaging due to tube Presentation
ht
decompression and passage of fluid from distended • Abdominal pain is a frequent complaint (30-49%)
o May lead to earlier presentation
tube into uterus or peritoneal cavity
o Associated findings include o Pain is colicky and lower abdominal
▪ Peritumoral ascites o Pain is caused by distension of partially blocked
▪ Intrauterine fluid collection fallopian tube by fluid, which is then relieved by
▪ Peritoneal implants passage of blood or discharge
• PET/CT • Latzko classical triad of symptoms reported in 15% of
o Can help identify site of primary tumor as PFTC in cases
o Intermittent profuse serosanguineous vaginal
patients with metastatic disease of unknown origin
o May detect unsuspected PFTC during staging of other discharge
o Colicky pain relieved by discharge
tumors, particularly breast carcinoma
o Adnexal mass
Staging • Hydrops tubae profluens
• PFTC is staged surgically, based on International o Intermittent discharge of clear or blood-tinged fluid
Federation of Obstetrics and Gynecology (FIGO) system spontaneously or on pressure followed by shrinkage
• Staging and operability mirror that of epithelial ovarian of adnexal mass
o Pathognomonic feature
cancer (EOC)
• Staging requires staging laparotomy, which includes o Occurs in 5% of patients 6
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Obgyne Books Full
• Clinical symptoms of PFTC and EOC are otherwise

similar and nonspecific REPORTING CHECKLIST
o Vaginal bleeding or spotting (50-60%)
o Abdominal or pelvic mass (60%)
T Staging
o Ascites (15%) • Characteristic imaging feature of PFTC is change in
appearance on serial imaging
Cancer Natural History & Prognosis o Due to accumulation of fluid within tube and
• Often diagnosed at earlier stage than EOC subsequent decompression into uterus or around
o Due to colicky abdominal pain resulting from tubal fimbrial end
distension • Evaluate tumor extension to adjacent pelvic structures
o Frequency of different stages at diagnosis o Ovaries, uterus, bladder, and rectum
▪ Stage I (20-35%) • Close attention to peritoneal implants
▪ Stage II (20-24%) o Both pelvic and abdominal implants
▪ Stage III (45-50%)
▪ Stage IV (3-10%)
N Staging
• Better survival compared to EOC • Paraaortic, pelvic, and inguinal nodes
• 5-year relative survival by stage M Staging
o Stage 0 (70%) • Attention to pleura, liver, vagina, and lungs
o Stage IA (85%)
o Stage IB: Not enough information to derive survival
t
ne
rate
o Stage IC (89%)
SELECTED REFERENCES
o Stage IIA (71%) 1. Shaaban AM et al: Imaging of primary fallopian tube
o Stage IIB (62%) carcinoma. Abdom Imaging. 38(3):608-18, 2013
e.
o Stage IIC (61%) 2. American Joint Committee on Cancer: AJCC Cancer Staging
o Stage IIIA (52%)
yn
3. Rabban JT et al: Ovarian pathology in risk-reducing
o Stage IIIB (43%) salpingo-oophorectomies from women with BRCA
o Stage IIIC (38%) mutations, emphasizing the differential diagnosis of occult
o Stage IV (22%) primary and metastatic carcinoma. Am J Surg Pathol.
bg 33(8):1125-36, 2009
Treatment Options 4. Wethington SL et al: Improved survival for fallopian tube
• Treatment options by stage cancer: a comparison of clinical characteristics and outcome
o Stage I for primary fallopian tube and ovarian cancer. Cancer.
ko
▪ Total abdominal hysterectomy and bilateral 113(12):3298-306, 2008

5. Hosokawa C et al: Bilateral primary fallopian tube
salpingo-oophorectomy with omentectomy
carcinoma: findings on sequential MRI. AJR Am J
▪ Systematic pelvic and paraaortic nodal dissection
oo
Roentgenol. 186(4):1046-50, 2006

is preferred to sampling (because of tendency for 6. Pectasides D et al: Fallopian tube carcinoma: a review.
early lymphatic spread) Oncologist. 11(8):902-12, 2006
▪ Undersurface of diaphragm should be visualized 7. Kosary C et al: Treatment and survival for women with
eb
and biopsied; pelvic and abdominal peritoneal Fallopian tube carcinoma: a population-based study.
biopsies and peritoneal washings should be Gynecol Oncol. 86(2):190-1, 2002
obtained routinely 8. Makhija S et al: Positron emission tomography/computed
▪ In patients who desire childbearing and have grade
://
tomography imaging for the detection of recurrent ovarian

and fallopian tube carcinoma: a retrospective review.
I tumors, unilateral salpingo-oophorectomy may Gynecol Oncol. 85(1):53-8, 2002
be associated with a low risk of recurrence
tp
9. Patel PV et al: PET-CT localizes previously undetectable

▪ No further treatment if low-grade cancer, possible metastatic lesions in recurrent fallopian tube carcinoma.
chemotherapy if high grade Gynecol Oncol. 87(3):323-6, 2002
ht
o Stage II 10. van Leeuwen BL et al: Liver metastasis as a first sign

▪ Total abdominal hysterectomy and bilateral of fallopian tube carcinoma and the role of positron
salpingo-oophorectomy + tumor debulking + emission tomography in preoperative diagnosis. Scand J
Gastroenterol. 37(12):1473-4, 2002
pelvic and paraaortic nodal dissection
11. Gadducci A et al: Analysis of treatment failures and survival
▪ Following surgery, combination chemotherapy ± of patients with fallopian tube carcinoma: a cooperation
radiation therapy task force (CTF) study. Gynecol Oncol. 81(2):150-9, 2001
o Stage III 12. Baekelandt M et al: Carcinoma of the fallopian tube. Cancer.
▪ Same as stage II; possible follow-up surgery to 89(10):2076-84, 2000
remove any remaining tumor 13. Slanetz PJ et al: Imaging of fallopian tube tumors. AJR Am J
o Stage IV Roentgenol. 169(5):1321-4, 1997
▪ Debulking surgery to remove as much of tumor as
possible, followed by combination chemotherapy
6
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Obgyne Books Full
Fallopian Tubes
a left-side hydrosalpinx
with nodular enhancing
mural lesions in a 70-year-
with vaginal bleeding and
crampy abdominal pain.
(Right) Coronal CECT
in the same patient at a
more anterior level shows
hydrosalpinx and an
enhancing mural nodule
. This was interpreted
as a multilocular adnexal
mass suspicious for cystic
epithelial ovarian neoplasm.
The patient refused surgery.
t
ne
e.
same patient, 6 months later,
yn
shows interval decrease in the
size of the left hydrosalpinx
and increase in the
size of the enhancing soft
bg
tissue component .
ko
interval decrease in the size
of the left-side hydrosalpinx
. The decrease in size
of hydrosalpinx is the
oo
radiological equivalent of
"hydrops tubae profluens," in
which the tube decompresses
eb
into the uterus resulting in less

tubal dilatation.
://

tp

same patient on her initial
presentation shows marked
ht
hydrosalpinx with small

mural enhancing nodule
the same patient 6 months
later shows decrease in the
size of hydrosalpinx and
increased size of enhancing
solid component . The
patient eventually agreed to
undergo surgery and was
found to have stage I (T1 N0
M0) serous fallopian tube
carcinoma.
6
47
Obgyne Books Full

(Left) Longitudinal
shows severe tubal dilatation
(hydrosalpinx) with an
echogenic mural nodule
. (Right) Transverse
hydrosalpinx with an
echogenic mural nodule ,
which demonstrates low-
resistance arterial flow. The
low-resistance arterial flow is
not specific for fallopian tube
carcinoma and is also seen in
both benign and malignant
ovarian lesions.
t
ne
e.
(Left) Axial NECT of the
pelvis obtained as part of
yn
PET/CT for the staging of
breast cancer shows normal-
appearing left adnexa
without identifiable mass.
bg
(Right) Axial PET/CT in
area of increased metabolic
ko
activity in the left adnexa
that appears elongated. It
is difficult on this image to
identify whether the location
oo
of increased activity is the left

ovary or fallopian tube.
eb
://

tp
(Left) Coronal fused PET/CT

that the area of increased
ht
metabolic activity has

a tubular configuration,
suggesting tubal origin.
(Right) Coronal PET in the
tubular, comma-shaped
configuration of the area of
increased metabolic activity
within the left adnexa.
No other areas of abnormal
metabolic activity were
detected. Fallopian tube
adenocarcinoma confined
to the tube was confirmed
during surgery.
6
48
Obgyne Books Full
Fallopian Tubes
with lower abdominal pain
shows a right adnexal cystic
structure without obvious
mural nodules. The density
of the lesion was 30 HU.
adnexal cystic structure .
The radiological interpretation
was a cystic adnexal mass,
likely hydrosalpinx or ovarian
cyst. Follow-up ultrasound in
6 weeks was recommended.
t
ne
e.
(Left) Longitudinal
yn
the same patient 6 weeks
after the CECT shows the
cystic adnexal structure
to be a dilated tube
bg
with an echogenic mural
nodule . (Right) Transverse
ko
hydrosalpinx with a
mural nodule . This was
found at surgery to be serous
oo
adenocarcinoma limited to
the fallopian tube.
eb
://
Stage IIA (T2a N0 M0) Stage IIA (T2a N0 M0)

tp

dilated left fallopian tube
containing mixed signal
ht
intensity material. The left

ovary is enlarged, pushed
toward the right side, and
cannot be separated from
the fimbrial end of the tube.
the same patient at a slightly
lower level shows the dilated
heterogeneous tube and
the enlarged heterogeneous
ovary .
6
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Obgyne Books Full

same patient shows left-sided
hydrosalpinx and filling
of the tube with material
that has low signal intensity
similar to that of fluid. The
subsequent gadolinium-
enhanced images help
separate enhancing tumor
from fluid/mucous filling
the tube. (Right) Sagittal
patient shows hydrosalpinx
with irregular thickening
and enhancement of the wall
of the fallopian tube.
t
ne
e.
yn
enhancement and nodular
thickening of the fallopian
tube wall as well as
bg
of the enlarged ovary .
MR shows enhancement
ko
and nodular thickening of
the fallopian tube wall ,
as well as heterogeneous
enhancement of the enlarged
oo
ovary . The dilated tube is

filled with tumor and bloody
fluid .
eb
://
Stage IIC (T2c N0 M0) Stage IIC (T2c N0 M0)

tp
(Left) Transverse
ht
presenting with increasing

abdominal girth shows a
left adnexal sausage-shaped
solid mass with internal
blood flow . (Right)
Transverse transabdominal
ultrasound in the same
patient shows ascites with
low-level internal echoes.
Abnormal anterior soft tissue
underneath the anterior
abdominal wall represents
omental metastases (caking).
6
50
Obgyne Books Full
Fallopian Tubes
Stage IIC (T2c N0 M0) Stage IIC (T2c N0 M0)
patient shows a solid left
adnexal mass between the
uterus and rectum. Extensive
omental metastatic disease
is seen anteriorly. (Right)
patient shows ascites and
enhancing omental metastatic
disease (omental caking)
forming a sheet of abnormal
tissue anterior to the bowel.
t
ne
e.
(Left) Axial CECT in a middle-
aged woman shows a
yn
sausage-shaped, mixed solid/
cystic right adnexal mass .
An enhancing left ovarian
nodule was found at
bg
surgery to be a metastatic
tumor. (Right) Axial CECT in
ko
sausage-shaped right adnexal
mass separate from the
enhancing right ovary .
During surgery, the right
oo
ovary was involved (T2a),

but the main bulk of the
mass was within the fallopian
eb
tube and arising from the

endosalpinx.
://

tp

patient shows right iliac
lymphadenopathy . (Right)
ht

patient at the level of the
kidneys shows retroperitoneal
lymphadenopathy . The
lymphatic drainage of the
fallopian tubes is similar to
the lymphatic drainage of the
ovaries, and tumor spreads
along the ovarian veins to the
retroperitoneal lymph nodes.
6
51
Obgyne Books Full

with vague pelvic pain
shows a fluid-filled sausage-
shaped tubular structure
(hydrosalpinx) anterior to
the vagina and superior
to the urinary bladder .
same patient shows the lateral
segment of the hydrosalpinx
with enhancing mural
nodule . The medial end
of the hydrosalpinx shows ill-
defined enhancement that
cannot be separated from the
uterus.
t
ne
e.
patient shows extensive left
yn
paraaortic and aortocaval
lymphadenopathy. (Right)
patient shows the sausage-
bg
shaped hydrosalpinx with
enhancing soft tissue tumor
at its uterine end. The
ko
location of the hydrosalpinx
inferior to the uterus is
unusual and is likely due to
the increased weight of the
oo
mucus-filled fallopian tube.

eb
://

tp

same patient shows almost
the entire length of the
ht
fluid-filled fallopian tube

located between the
uterus and the partially
filled urinary bladder .
paraaortic and aortocaval
lymphadenopathy. Left
tubal adenocarcinoma
involving the uterus with
retroperitoneal metastatic
disease was confirmed during
surgery.
6
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Obgyne Books Full
Fallopian Tubes
presented with abdominal
pain shows a sausage-shaped,
predominantly cystic mass
with mural papillary
projections . (Right)
patient shows the cystic mass
arising from the left cornu
of the uterus . The solid
component of the mass
extends through the wall and
invades the rectum .
t
ne
e.
same patient at a lower level
yn
shows tumor invading the
bladder as well as the
rectum . (Right) Axial
bg
shows an enlarged necrotic
left paraaortic lymph node
ko
.
oo
eb
://

tp

the cystic component of
ht
the mass as well as the

solid component with
invasion of the wall of the
rectum . (Right) Coronal
shows tumor invading the
wall of the urinary bladder
with enhancement of
the bladder mucosa .
Tumor extension to pelvic
organs other than the uterus
and ovaries constitutes T2b
disease.
6
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Obgyne Books Full
Fallopian Tubes HEMATOSALPINX
Key Facts
• Blood-filled fallopian tube • Pyosalpinx
• Hematosalpinx is a finding, not a diagnosis • Noncommunicating uterine horn
Imaging • Peritoneal inclusion cyst
• Tubular structure interposed between uterus and ovary Pathology
containing complex fluid • Etiology
• Incomplete septations o Ectopic pregnancy
• Hyperdense on CT o Pelvic inflammatory disease (PID)
• ↑ T1, variable T2 o Endometriosis
• Secondary findings depend on etiology of o
o
Tuboplasty
hematosalpinx Intrauterine device (IUD)
• Subtraction images may be helpful due to intrinsic T1 o
o
Tubal ligation
signal Müllerian duct anomalies
• Once hematosalpinx identified, try to find etiology o Assisted reproductive technique
• MR can supplement TVUS for assessment of etiology of o
o
Cervical stenosis
t
hematosalpinx Fallopian tube carcinoma
ne
e.
yn
ultrasound shows a tubular
hypoechoic adnexal mass
with incomplete septations
bg
and posterior acoustic
enhancement. (Right)
Axial T2WI FSE MR in
ko
homogeneously hyperintense
tubular left adnexal structure
. Separate ovary is not
oo
shown. The folded tubular

shape and incomplete
septations are compatible
eb
with a dilated fallopian tube.

://
tp
ht

of the dilated left fallopian
tube. (Right) Axial T1WI C+
FS MR demonstrates persistent
hyperintensity of the tube
contents confirming blood
products and hematosalpinx
. Subtraction (postcontrast -
precontrast) would be helpful
to exclude a solid enhancing
component in hematosalpinx
or any lesion with intrinsic
T1 signal. Hematosalpinx has
many etiologies and in this
case was thought to be due
to longstanding intrauterine
device .
6
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Obgyne Books Full
HEMATOSALPINX
Fallopian Tubes
TERMINOLOGY Peritoneal Inclusion Cyst
Definitions
• Complex cystic mass with entrapped or eccentrically
located ovary
• Blood-filled fallopian tube • Usually not hemorrhagic
• Hematosalpinx is a finding, not a diagnosis
PATHOLOGY
IMAGING
General Features
General Features • Etiology
• Best diagnostic clue o Ectopic pregnancy (EP)
o Tubular structure interposed between uterus and o Pelvic inflammatory disease (PID)
ovary containing complex fluid o Endometriosis
o Incomplete septations o Tuboplasty
o Folded appearance of tube may mimic a complex o Intrauterine device (IUD)
cystic adnexal mass o Tubal ligation
o Secondary findings depend on etiology of o Müllerian duct anomalies
hematosalpinx o Assisted reproductive technique
o Cervical stenosis
CT Findings o
t
• Distention of tube with hyperdense fluid
Fallopian tube carcinoma
ne
MR Findings
• T1WI • Distended blood-filled fallopian tube
e.
o High signal intensity (SI) tubular adnexal structure
• T2WI CLINICAL ISSUES
o Variable SI tubular adnexal structure
yn
Presentation
▪ Low SI if associated with different stages of blood
products similar to endometriomas • Most common signs/symptoms
o Varies with etiology
▪ High SI if methemoglobin
bg
• T1WI C+ FS Demographics
o Tubular adnexal structure with wall enhancement
o Intrinsic T1 signal may obscure enhancing solid mass
• Epidemiology
o Incidence is 1% in general population increasing to
ko
▪ Subtraction images (postcontrast minus 10% when previous history of EP

precontrast) are helpful to see solid component
• Natural history and prognosis of hematosalpinx reflects
oo
• Tubular adnexal structure distended with echogenic etiology
material
• Incomplete septations Treatment
eb
• Separate ovary • Varies with etiology of hematosalpinx

://
• Best imaging tool DIAGNOSTIC CHECKLIST

o TVUS is first-line imaging examination Consider
o MR can supplement TVUS for assessment of etiology
• Tubal EP with hematosalpinx is usually in close
tp
of hematosalpinx proximity to ovary (within 2 cm)

• Protocol advice
ht
o Scanning in multiple planes will allow "elongation" Image Interpretation Pearls

of tube and aid diagnosis • Folded appearance of tube in hematosalpinx may
o Once hematosalpinx identified, try to find etiology mimic a complex cystic adnexal mass
DIFFERENTIAL DIAGNOSIS SELECTED REFERENCES

Pyosalpinx imaging algorithm. Radiographics. 32(4):1047-64, 2012
• Distended fallopian tube containing particulate 2. Siegelman ES et al: MR imaging of endometriosis: ten
material and hypervascular wall imaging pearls. Radiographics. 32(6):1675-91, 2012
• Enlarged ovary 3. Rezvani M et al: Fallopian tube disease in the nonpregnant
• Accompanied by pelvic inflammation 4.
Moyle PL et al: Nonovarian cystic lesions of the pelvis.
Noncommunicating Uterine Horn Radiographics. 30(4):921-38, 2010
• Associated myometrium contiguous with remainder of 5. Kim MY et al: MR Imaging findings of hydrosalpinx: a
comprehensive review. Radiographics. 29(2):495-507, 2009
uterus 6. Krasevic M et al: Serous borderline tumor of the fallopian
tube presented as hematosalpinx: a case report. BMC
Cancer. 5:129, 2005
6
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Obgyne Books Full
t
ne
e.
yn
bg
ko
oo
eb
://
tp
ht
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Untitled-1 1 14-08-15 12:40 PM

SECTION 7
Multiorgan Disorders
Malignant Neoplasms
t
ne
Genital Lymphoma 7-2
Genital Metastases 7-8
e.
Abnormal Sexual Development
yn
Androgen Insensitivity Syndrome 7-14
Ambiguous Genitalia 7-16
Gonadal Dysgenesis 7-20
bg
ko
oo
eb
://
tp
ht
Obgyne Books Full

Multiorgan Disorders GENITAL LYMPHOMA
Key Facts
Terminology • Most lymphomas of genital tract are diffuse large B-cell
• Lymphoma involving uterus, cervix, vagina, or vulva non-Hodgkin lymphomas or Burkitt lymphoma
• Primary Burkitt lymphoma of uterus, vagina, and
Imaging cervix seen in children and adolescents
• Homogeneous myometrial, vaginal, or vulvar mass/ • Ovaries are often involved in cases of secondary
masses with moderate contrast enhancement lymphoma
• Diffuse infiltration of uterus, cervix, and vagina • Occasional follicular lymphomas are seen
• May have involvement of lymph nodes or other viscera Clinical Issues
• Vaginal bleeding and discharge
if genital tract is secondarily involved
• MR is modality of choice to detect multiple lesions • Rarely systemic symptoms such as fever and weight loss
within uterus, diffuse enlargement of vagina, and
extent of vulvar involvement (B symptoms)
• PET/CT can be performed for staging and to exclude • Patients with primary uterine, vaginal, or cervical
other sites of lymphoma lymphoma generally have intermediate- or high-grade
• Diffusion imaging is quite useful lymphoma type and poorer prognosis than patients
with secondary lymphoma of uterus
Pathology
• Can be associated with HIV infection
t
ne
e.
yn
in the pelvis of 44-year-old
woman with HIV and weight
loss shows diffuse soft tissue
bg
infiltration of the uterine
myometrium and cervix ,
and enlarged necrotic pelvic
ko
lymph nodes . Endometrial
sampling proved it to be
Burkitt lymphoma. (Right)
Axial CECT lower down in the
oo
same patient shows soft tissue

cavity by Burkitt lymphoma
eb
and large necrotic pelvic

lymphadenopathy , also
sampled and proven to be
Burkitt lymphoma.
://
tp
ht
(Left) Axial CECT of a 32-year-

old patient presenting with
pelvic fullness shows a large
soft tissue mass with central
necrosis replacing the
uterus and filling the pelvic
inlet. Endometrial sampling
proved to be a primary uterine
diffuse large B-cell lymphoma.
patient with primary uterine
lymphoma shows expansion
and replacement of the uterus
with heterogeneous soft tissue
and necrotic mass .
7
2
Obgyne Books Full
GENITAL LYMPHOMA
TERMINOLOGY Imaging Recommendations
Definitions
o MR is modality of choice to detect multiple lesions
• Primary uterine, vaginal, or vulvar lymphoma within uterus, diffuse enlargement of vagina, and
o Extranodal non-Hodgkin lymphoma (NHL), of extent of vulvar involvement
genital tract o PET/CT can be performed for staging and to exclude
▪ Either uterus (including cervix &/or corpus), other sites of lymphoma
vagina, or vulva • Protocol advice
• Secondary uterine lymphoma o T1WI, T2WI, and T1WI C+ MR
o Genital involvement is part of a generalized process ▪ Diffusion-weighted imaging is quite useful
(40-50% of patients with lymphoma at autopsy),
cervix, vagina, or vulva
IMAGING Leiomyoma of Uterus, Vagina, or Cervix
• Very common
General Features • Benign solitary or multiple intramural, subserosal, or
• Best diagnostic clue submucosal solid masses
o Homogeneous myometrial mass(es), vagina and
• Low signal intensity on all MR sequences
t
vulva with moderate contrast enhancement
ne
o Diffuse infiltration of uterus, cervix, and vagina Endometrial, Vaginal, or Cervical Carcinoma
• Location • Tumor of endometrial origin with possible myometrial
o Uterine corpus, cervix, vagina, and vulva invasion and spread to regional lymph nodes
▪ May involve both endometrium and myometrium • MR demonstrates diffuse or polypoid thickening of
e.
o Cervix, rather than uterine corpus, is more often site endometrium ± invasion of junctional zone
of initial manifestation Genital Sarcomas
yn
• Size
• Leiomyosarcoma
o Ranges from small masses to diffuse involvement of o Relatively rare, aggressive, malignant neoplasm
uterus, cervix, vagina, and vulva
bg arising from smooth muscle cells of myometrium,
• Morphology vagina, and vulva
o Densely packed cells give lymphoma a uniform o Generally associated with bad prognosis due to
appearance, regardless of imaging modality widespread metastatic disease
ko
CT Findings • Rhabdomyosarcoma
• Diffuse uterine enlargement or local masses involving o Aggressive malignant pediatric tumor
o Arises from upper vagina and uterus
oo
uterus, cervix, &/or vagina

o May have involvement of lymph nodes or other • Other uterine sarcomas
viscera if uterus is secondarily involved o Mixed müllerian tumor
o Endometrial stromal sarcoma
eb
MR Findings
• T1WI PATHOLOGY
o Mass or masses isointense to muscle
o Enlarged lymph nodes in case of secondary
://
General Features
•
involvement by lymphoma
T2WI
• Etiology
o Chronic polyclonal activation of B cells due to
tp
o Diffusely enlarged uterus with a somewhat lobular

longstanding infections may be one of the etiologic
contour factors
ht
o Single or multiple homogeneous masses of uterus,

cervix, &/or vagina
• Genetics
o Primary Burkitt lymphoma of uterus, vagina, and
o Slightly hyperintense to muscle
o Coexistent cervical involvement typically preserves cervix seen in children and adolescents
o Characterized by translocation of MYC (c-myc ) gene
high-signal endocervical canal
• T1WI C+
on chromosome 8 and immunoglobulin heavy chain
(IgH) on chromosome 14
o Moderate homogeneous enhancement
▪ Associated lymph nodes enhance similar to
o Can be associated with HIV infection
lymphomatous involvement of uterus, vagina, o Ovaries are often involved in cases of secondary
cervix, and vulva
lymphoma
Ultrasonographic Findings Staging, Grading, & Classification
• Enlarged globular uterus, diffusely enlarged cervix and • Ann Arbor and American Joint Committee on Cancer
vagina
• Ill-defined hypoechoic masses of groin in case of (AJCC)
o Stage IE: Single extralymphatic organ or site (i.e.,
associated inguinal adenopathy
• Occasionally polypoid endometrial mass uterus)
▪ "E" is for extranodal
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o Stage IIE: Localized involvement of one Natural History & Prognosis

extralymphatic organ and its regional lymph
nodes with or without other nodes on same side of
• Patients with primary uterine, vaginal, or cervical
lymphoma generally have intermediate- or high-grade
diaphragm lymphoma type and poorer prognosis than patients
o Stage III: Involvement of lymph node regions on with secondary lymphoma of uterus
both sides of diaphragm
o Stage IV: Diffuse or disseminated involvement of ≥ 1
• Interval of several months between detection of uterine
lesion and appearance of any secondary lesions
extralymphatic organs or tissues (e.g., bone marrow,
liver) ± associated node enlargement Treatment
• Chemotherapy and radiotherapy; therefore,
differentiation from surgically treated genital
• Uterus, cervix, and vagina may be moderately enlarged malignancies is crucial
• Uterine corpus, vaginal, or cervical lesions can form
polypoid masses or diffusely replace with endometrium
• Vulvar lymphoma can be diffusely infiltrating with DIAGNOSTIC CHECKLIST
central necrosis Consider
• Cut surface is fleshy, rubbery, white, or tan and may • NHL in a work-up of genital neoplasms, even without
have areas of hemorrhage or necrosis evidence of nongenital lymphomatous involvement
t
• Most are diffuse large B-cell non-Hodgkin lymphomas • Lymphoma typically remains homogeneous by
ne
or Burkitt lymphoma
• Occasional follicular lymphomas are seen
imaging even when large
• Infiltration of vessels is typical
e.
• Rare types include SELECTED REFERENCES
o Marginal zone lymphoma 1. Alves Viera MA et al: Primary lymphomas of the female
yn
o T-cell lymphoma genital tract: imaging findings. Diagn Interv Radiol.
• Immunohistochemistry is positive for
2.
20(2):110-5, 2014
Merritt AJ et al: Primary extranodal marginal zone B cell
o CD45: Lymphoid cells
o C 20 and CD79a: B-cell lymphoma
bg lymphoma of the uterus: a case study and review of the
literature. J Clin Pathol. 67(4):375-7, 2014
o CD3: T-cell lymphoma 3. Salem U et al: Hematopoietic tumors of the female genital
• Flow cytometry demonstrates a monoclonal B-cell system: imaging features with pathologic correlation.
ko
population and cell surface antigens Abdom Imaging. Epub ahead of print, 2014
• Must distinguish it histologically from 4. Hashimoto A et al: [Primary diffuse large B-cell lymphoma
of the uterine cervix successfully treated with rituximabplus
o Benign lymphoma-like lesion
cyclophosphamide, doxorubicin, vincristine, and
▪ Demonstrates polyclonality
oo
prednisone chemotherapy-a case report.] Gan To Kagaku

o Small cell carcinoma Ryoho. 40(13):2589-92, 2013
▪ Immunoreactivity for synaptophysin, CD56, 5. Isosaka M et al: [Primary diffuse large B-cell lymphoma
eb
chromogranin of the uterus complicated with hydronephrosis.] Rinsho

o Endometrial stromal sarcoma Ketsueki. 54(4):392-6, 2013
▪ Immunoreactivity for CD10, actin, and vimentin; 6. Onyiuke I et al: Primary gynecologic lymphoma: imaging
negative for CD45 findings. AJR Am J Roentgenol. 201(4):W648-55, 2013
://
7. Ragupathy K et al: Primary vaginal non-Hodgkin

lymphoma: gynecologic diagnosis of a hematologic
CLINICAL ISSUES malignancy. J Low Genit Tract Dis. 17(3):326-9, 2013
tp
8. Sugimoto KJ et al: Diffuse large B-cell lymphoma of the

Presentation uterus suspected of having transformed from a marginal
• Most common signs/symptoms zone B-cell lymphoma harboring trisomy 18: a case
ht
o Vaginal bleeding, discharge, pain report and review of the literature. Int J Clin Exp Pathol.
•
6(12):2979-88, 2013
Other signs/symptoms 9. Sohaib SA et al: Imaging of uterine malignancies. Semin
o Rarely systemic symptoms such as fever and weight Ultrasound CT MR. 31(5):377-87, 2010
loss (B symptoms) 10. Goto N et al: Magnetic resonance findings of primary
o Can be asymptomatic and discovered incidentally by uterine malignant lymphoma. Magn Reson Med Sci.
abnormal cytology on routine pelvic exam 6(1):7-13, 2007
11. Niwa K et al: Primary lymphoma of the uterine corpus: an
Demographics unusual location for a common disease--case report. Eur J
• Age Gynaecol Oncol. 28(6):522-3, 2007
o Mean: 53 (range: 8-85) 12. Hamadani M et al: Marginal zone B-cell lymphoma of the
• Epidemiology
uterus: a case report and review of the literature. J Okla State
Med Assoc. 99(4):154-6, 2006
o Initial uterine, vaginal, or cervical involvement 13. Keller C et al: Primary Burkitt lymphoma of the uterine
occurs in only 1% of patients with lymphoma corpus. Leuk Lymphoma. 47(1):141-5, 2006
o Secondary involvement by lymphoma is much more 14. Lagoo AS et al: Lymphoma of the female genital tract:
common than primary and has been seen in up to current status. Int J Gynecol Pathol. 25(1):1-21, 2006
10% of women with documented lymphoma
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GENITAL LYMPHOMA
(Left) Axial FDG PET/CT images
presented for staging in her
recent diagnosis of diffuse
large B-cell lymphoma after
presenting with longstanding
vaginal bleeding show marked
FDG-18 avidity in the primary
uterine lymphomatous mass
and associated left pelvic nodes
. (Right) Axial CECT in a 25-
year-old woman with weight
loss shows a soft tissue uterine
and right adnexal mass .
Endometrial sampling proved
Burkitt lymphoma of the uterus
t
and adnexa.
ne
e.
yn
patient shows a diffusely
infiltrating soft tissue uterine
bg and right adnexal mass .
Endometrial sampling proved
Burkitt lymphoma of the uterus
and adnexa. (Right) Axial CECT
ko

abdominal pain shows a large
soft tissue pelvic mass replacing
oo
the uterus with bulky soft

tissue filling in the pelvic inlet
replacing the adnexae .
Pathology from endometrial
eb
biopsy proved large B-cell

lymphoma.
://
tp
ht

same patient shows the large
lymphomatous mass
replacing the uterus and cervix.
Note the soft tissue extent
in this patient with large B-
cell lymphoma. (Right) Axial
FDG PET/CT images in a
patient with diffuse large cell
lymphoma of the uterus shows
marked FDG-18 avidity in the
lymphomatous uterine mass
as well as tumor activity in
the adnexa and parametrial soft
tissues of the pelvis.
7
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ultrasound image in a 52
year old with history of
follicular cell lymphoma and
vaginal spotting shows a large
echogenic mass replacing the
vagina . Tissue sampling
proved conversion to a diffuse
large B-cell lymphoma. (Right)
shows internal vascularity
of the solid echogenic mass
replacing the vagina in this
patient with diffuse large B-cell
lymphoma.
t
ne
e.
yn
with history of follicular cell
lymphoma shows an exophytic
bg
densely enhancing mass
arising from the right vaginal
fornix . This was shown to
ko
be a biopsy-proven isolated
deposit of diffuse large B-
cell lymphoma, thought to
oo
be conversion from her low-

grade lymphoma. (Right)
eb
nodular enhancing large

cell lymphoma deposit
centered in the vagina.
://
tp
ht

MR in a female with diffuse
lymphomatous replacement
of the uterine myometrium
with T2-hyperintense tissue
with relative sparing of the
endocervix and the cervical
T2 dark cervical stroma .
Tissue sampling proved diffuse
lymphoma of the uterus.
(Right) Sagittal T2WI FSE
lymphomatous replacement
of the uterus shows the
smooth, globular nature and
infiltration of the uterus by
lymphoma with sparing of the
endocervix.
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GENITAL LYMPHOMA
metrorrhagia shows diffuse mass-
like soft tissue thickening and
replacement of the vagina with
T2-isointense tissue . Tissue
sampling proved diffuse large
B-cell lymphoma. (Right) Axial
patient with vaginal diffuse large
B-cell lymphoma shows dense
of the lymphomatous vaginal
mass.
t
ne
e.
yn
(Left) Sagittal T2WI FSE MR in a
35 year old with vaginal diffuse
large B-cell lymphoma shows
bg a large, infiltrating, relatively
smooth mass replacing the
entire vagina and vaginal fornices
. (Right) Sagittal T1WI C+
ko
FS MR in the same patient with

diffuse large B-cell lymphoma of
the vagina shows homogeneous
oo
enhancement of the infiltrating

vaginal mass .
eb
://
tp
ht

old girl presenting with failure to
thrive shows diffuse soft tissue
infiltrating and replacing the
entire peritoneal cavity of the
pelvis and genital organs .
Tissue sampling proved Burkitt
lymphoma. (Right) Axial CECT
in the same 6-year-old girl with
Burkitt lymphoma shows the
diffuse soft tissue lymphomatous
mass infiltrating and replacing
the entire pelvis and genital
organs .
7
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Multiorgan Disorders GENITAL METASTASES
Key Facts
• Secondary malignancy of uterus, cervix, or vagina • Metastases are more common than primary
o Either from systemic metastatic disease or from malignancies of vagina
direct extension from adjacent pelvic malignancy o Primary uterine or cervical malignancies more
common than metastases
Imaging • Ovary, rectum, kidney, and breast are other common
• Variable enhancement of secondary tumor in uterus, primaries
cervix, or vagina • Vaginal stump is most common site for local
• FDG-18 uptake in metastases to genital organs and recurrence after surgery for uterine and cervical
other regions in body; can differentiate mets from malignancies
posttreatment change and fibrosis
• CT and MR are most commonly used to detect genital Clinical Issues
metastases and assess extent of disease • Abnormal vaginal bleeding, discharge, and pain
Top Differential Diagnoses • Surgery &/or chemoradiation
• Primary uterine, cervical, or vaginal malignancy Diagnostic Checklist
• Post-radiation changes • Role of imaging is to define extent of disease and
• Uterine, cervical, or vaginal lymphoma
t
differentiate radiation changes from recurrent tumor
ne
e.
yn
MR of the pelvis in a 56-
year-old woman with
remote history of mucinous
bg
adenocarcinoma of the colon
shows a hyperenhancing
mass centered in the vaginal
ko
cuff . Transvaginal biopsy
pathology showed metastatic
mucinous tumor similar to
primary carcinoma. (Right)
oo

same patient with metastatic
mucinous adenocarcinoma
eb
to the vagina shows a

hyperintense exophytic
polypoid mass expanding the
entire vaginal cuff .
://
tp
ht

year-old woman with vaginal
bleeding shows a large
necrotic cervical mass
involving the right vaginal
fornix . Biopsy specimen
proved it to be a necrotic
cervical carcinoma. (Right)
Axial CECT of the same patient
with cervical carcinoma shows
the necrotic mass extending
into the right vaginal fornix ,
with foci of internal gas.
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GENITAL METASTASES
TERMINOLOGY ▪ Can present with diffuse enlargement of
myometrium and cervix
Synonyms – Can serve as a guide for tissue sampling
• Uterine, cervical, or vaginal metastases • Color Doppler
o Internal vascularity may be detected in solid masses
Definitions
• Secondary malignancy of uterus, cervix, or vagina Nuclear Medicine Findings
• PET
o Accurately demonstrates central recurrence or
IMAGING metastases to uterus, cervix, or vagina in patients
General Features with undetermined findings on CT or MR
▪ Can detect recurrences or metastases in small
• Best diagnostic clue lesions < 1 cm in vaginal cuff, retrovesical area,
o Solid or mixed solid and cystic mass involving uterus,
and pelvic wall, where it is difficult to differentiate
cervix, or vagina
▪ Either from systemic metastatic disease or from between fibrosis and recurrence
direct extension from adjacent pelvic malignancy Imaging Recommendations
(peritoneum, colon)
▪ Known primary malignancy, with hematogenous
o CT and MR are most commonly used to detect
spread to uterus, cervix, or vagina
t
uterine, cervical, or vaginal metastases and assess
– Recurrence of primary gynecologic malignancy
ne
extent of disease
to vaginal cuff o FDG-18 PET imaging can be helpful for staging of
• Location metastases
o Uterus, cervix, vagina, or vulva
•
e.
Protocol advice
• Size o MR with dedicated phased-array coil
o Varies; can present as large bulky tumors ▪ High-resolution T2W imaging in sagittal, coronal,
•
yn
Morphology and axial planes
o Sessile or polypoid mass between bladder and rectum – Dynamic post-contrast T1WI with fat saturation
in the case of metastases to vaginal stump – DWI useful
▪ Polypoid masses of uterine corpus, cervix, or
bg
vagina with hematogenous metastases
▪ Diffuse globular infiltration of the uterus, cervix, DIFFERENTIAL DIAGNOSIS
ko
or vagina Primary Uterine, Cervical, or Vaginal Malignancy
CT Findings • Primary malignancies have similar imaging
• CECT characteristics
oo
o Variable enhancement of secondary tumor in uterus, Post-Radiation Changes

cervix, or vagina
▪ Central necrosis and irregular enhancement
• Diffuse vaginal, rectal, and bladder wall thickening can
be associated features on imaging following completion
eb
common of radiation treatment

▪ May see primary tumor in adjacent pelvic organs
with local extension
• Post-radiation fibrosis is of low signal intensity on
T1WI and T2WI
://
– May see other metastatic lesions in liver, lung, or o Typically demonstrates delayed enhancement
peritoneum
Uterine, Cervical, or Vaginal Lymphoma
• Homogeneous masses or diffuse globular enlargement
tp
MR Findings
• T1WI of uterus, cervix, vagina, or vulva
o Hypointense or isointense T1 signal intensity o Nodal disease elsewhere in abdomen or pelvis
ht
• T2WI
o Presence of discrete, measurable, heterogeneous high
PATHOLOGY
signal intensity on T2
• DWI General Features
o Marked diffusion restriction in metastases of genital • Vaginal metastases from primary endometrial and
organs cervical carcinomas are more common than primary
▪ May see diffusion restriction in other metastatic malignancies of vagina
lesions; useful for peritoneal implants o Vaginal stump is most common site for local
• T1WI C+ recurrence after surgery for uterine and cervical
o Variable enhancement malignancies
▪ Can have central regions of hemorrhage or necrosis ▪ 15% of patients experience local recurrence at
if metastatic lesion is large vaginal stump or pelvic wall without distant
metastases (central recurrence)
Ultrasonographic Findings ▪ Incidence of central recurrence varies with stage at
• Grayscale ultrasound presentation, histologic type, adequacy of therapy
o Echogenic discrete polypoid uterine, cervical, or
used, and host response
vaginal mass
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o However, primary uterine and cervical malignancies 2. Carreras C et al: Rare metastases detected by (68)Ga-
are more common than metastases somatostatin receptor PET/CT in patients with
• Metastases often result from direct extension of neuroendocrine tumors. Recent Results Cancer Res.
194:379-84, 2013
peritoneal, vulvar, or colorectal primary malignancies
3. Sanuki N et al: Evaluation of microscopic tumor extension
o Systemic metastases from ovary, rectum, kidney,
in early-stage cervical cancer: quantifying subclinical
melanoma, and breast are other common primaries uncertainties by pathological and magnetic resonance
to metastasize to cervix and vulva imaging findings. J Radiat Res. 54(4):719-26, 2013
▪ Breast and colon are most frequent primary sites to 4. Alt CD et al: Imaging of female pelvic malignancies
metastasize to uterus regarding MRI, CT, and PET/CT: Part 2. Strahlenther Onkol.
▪ Other primaries include stomach, pancreas, 187(11):705-14, 2011
gallbladder, lung, skin, urinary bladder, and 5. Brocker KA et al: Imaging of female pelvic malignancies
regarding MRI, CT, and PET/CT : part 1. Strahlenther Onkol.
thyroid gland
187(10):611-8, 2011
▪ Neuroendocrine tumor is also not an uncommon 6. Fischerova D: Ultrasound scanning of the pelvis and
primary to metastasize to uterus, cervix, and abdomen for staging of gynecological tumors: a review.
vagina Ultrasound Obstet Gynecol. 38(3):246-66, 2011
o Possible mechanism of metastasis to uterus includes 7. Levy A et al: Interest of diffusion-weighted echo-planar
direct intraluminal spread from ovary through MR imaging and apparent diffusion coefficient mapping
fallopian tube in gynecological malignancies: a review. J Magn Reson
Imaging. 33(5):1020-7, 2011
t
8. Bogliolo S et al: Breast cancer with synchronous massive
•
ne
Sessile or polypoid mass in uterus, cervix, or vagina metastasis in the uterine cervix: a case report and review of
o Uterus involved diffusely, involving both the literature. Arch Gynecol Obstet. 281(4):769-73, 2010
9. Cagayan MS: Vaginal metastases complicating gestational
endometrium and myometrium
trophoblastic neoplasia. J Reprod Med. 55(5-6):229-35, 2010
▪ Mucinous colorectal or gastric primaries may result
e.
10. Ceccaroni M et al: Symptomatic vaginal bleeding in a
in tumor calcification in uterus postmenopausal woman revealing colon adenocarcinoma
▪ Diffuse involvement of uterine myometrium can metastasizing exclusively to the vagina. J Minim Invasive
yn
extend to involve cervix or vagina Gynecol. 17(6):779-81, 2010
▪ Vulvar soft tissue mass can involve Bartholin 11. Colling R et al: Endometrial metastasis of colorectal cancer
glands with coincident endometrial adenocarcinoma. BMJ Case
o Central recurrences or metastases may grow with
bg Rep. 2010, 2010
12. D'souza MM et al: Cervical and uterine metastasis from
contiguous spread to urinary bladder or rectum
carcinoma of breast diagnosed by PET/CT: an unusual
presentation. Clin Nucl Med. 35(10):820-3, 2010
ko
CLINICAL ISSUES 13. Grant LA et al: Congenital and acquired conditions of

the vulva and vagina on magnetic resonance imaging: a
Presentation pictorial review. Semin Ultrasound CT MR. 31(5):347-62,
oo
2010
14. Sahdev A: Cervical tumors. Semin Ultrasound CT MR.
o Abnormal vaginal bleeding or discharge
31(5):399-413, 2010
▪ Systemic symptoms of weight loss, leg edema, 15. Sohaib SA et al: Imaging of uterine malignancies. Semin
eb
pelvic pain usually indicate advanced metastatic Ultrasound CT MR. 31(5):377-87, 2010
disease 16. Sundaram PS et al: Staring secondaries, where is the
▪ Vulvar mass can present with drainage, nonhealing primary? Indian J Med Paediatr Oncol. 31(4):148-50, 2010
17. Griffin N et al: Magnetic resonance imaging of vaginal and
://
ulcer, and itching

vulval pathology. Eur Radiol. 18(6):1269-80, 2008
Treatment 18. Kang WD et al: Hepatocellular carcinoma presenting as
•
tp
Surgery &/or chemoradiation uterine metastasis. Cancer Res Treat. 40(3):141-4, 2008
o Radiation therapy including high-dose radiation 19. Parikh JH et al: MR imaging features of vaginal
malignancies. Radiographics. 28(1):49-63; quiz 322, 2008
(brachytherapy) for recurrence
ht
20. Hauth EA et al: [Magnetic resonance imaging in the

diagnosis of benign and malignant pelvic tumors.] Rofo.
Consider
• Diagnosis is usually made clinically
• Role of imaging is to define extent of disease and
differentiate radiation changes from recurrent tumor
• Mass in uterus, cervix, or vagina or diffuse globular
mural wall thickening in a patient with known
malignancy
SELECTED REFERENCES
1. Burger IA et al: The value of 18F-FDG PET/CT in recurrent
gynecologic malignancies prior to pelvic exenteration.
7 Gynecol Oncol. 129(3):586-92, 2013
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GENITAL METASTASES
patient with a history of colon
carcinoma shows an expansile
exophytic vaginal mass . Note
the marked T2 hyperintensity
of this mass corresponding to
the mucin-rich tumor. (Right)
Sagittal T2WI C+ FS MR in this
patient with metastatic mucinous
adenocarcinoma shows the
exophytic cauliflower-like mass
growing out of the tumor-
filled vaginal cavity .
t
ne
e.
yn
extent of the vaginal metastatic
bg deposit . (Right) Axial T2WI
C+ FS MR of the pelvis shows
the expansile enhancing vaginal
metastases .
ko
oo
eb
://
tp
ht

64-year-old woman with poorly
differentiated adenocarcinoma
of the rectum with mucinous
features shows innumerable
small cystic metastatic deposits
completely replacing the vaginal
wall extending to encase the
urinary bladder base . (Right)
Axial T2WI FSE MR in the same
patient with adenocarcinoma
small T2 hyperintense metastatic
foci studding the vaginal wall ,
bladder base , and rectum .
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the same patient with poorly
differentiated adenocarcinoma
small T2 hyperintense
metastatic foci replacing the
vaginal wall and urethra
. Surgical biopsy specimen
confirmed metastatic disease
to the vagina. (Right) Axial
T1WI C+ FS MR in a patient
presenting for staging for rectal
adenocarcinoma shows a
peripherally enhancing rectal
tumor extending and
t
invading the left vaginal fornix
ne
.
e.
yn
the same patient with rectal
adenocarcinoma shows the
infiltrative nature of the rectal
bg
tumor invading the vagina
and left pelvic sidewall
ko
shows the soft tissue rectal

carcinoma invading the vagina,
with loss of the normal soft
oo
tissue plane . The vaginal

metastasis demonstrates T2
signal similar to the primary
rectal tumor .
eb
://
tp
ht

patient presenting for staging
of recently diagnosed cervical
carcinoma shows the cervical
tumor extending inferiorly and
invading the vagina . (Right)
Axial T1WI C+ FS MR of the
cervical carcinoma shows the
enhancing tumor involving the
upper vagina .
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GENITAL METASTASES
neuroendocrine tumor of
the appendix shows a large
mass filling the entire pelvis ,
involving the uterus and adnexa
. Surgical debulking of the
uterus and adnexa confirmed
metastatic neuroendocrine tumor
the same patient with metastatic
neuroendocrine tumor shows
the extensive involvement of the
pelvis by the aggressive tumor
.
t
ne
e.
yn
presented with vaginal bleeding
bg shows a large infiltrating
tumor replacing the uterine
myometrium and cervical
stroma . Tissue sampling
ko
proved it to be metastatic
neuroendocrine tumor. (Right)
Axial T1WI C+ FS MR centered
oo
in the pelvis in the same patient

shows the large neuroendocrine
tumor replacing the cervix .
eb
://
tp
ht

in a woman with metastatic
neuroendocrine tumor shows
a large avidly enhancing
mass replacing the uterine
myometrium and cervix .
(Right) Axial CECT image in the
pelvis in a 39-year-old woman
with diffuse metastatic breast
carcinoma shows the ill-defined
uterus replaced by tumor
and bilateral heterogeneously
enhancing adnexal masses ,
consistent with Krukenberg
tumors.
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Multiorgan Disorders ANDROGEN INSENSITIVITY SYNDROME
Key Facts
• Synonyms: Complete androgen insensitivity • Androgen resistance due to absence of receptor
syndrome (CAIS), testicular feminization protein, changes in receptor protein structure
• 46,XY karyotype with female phenotype with (receptor-negative) or post-receptor defect (receptor-
functioning testes but end-organ resistance to positive)
androgens • Androgen receptor defect → no response to
• Results in 46,XY "undermasculinized genitalia" and testosterone signal → undermasculinization of
phenotypic female external genitalia in utero and deficient virilization at
puberty
Imaging • Müllerian regression factor produced by testes →
• Bilateral undescended testes absent or rudimentary müllerian structures
• Uterus, fallopian tube, and upper vagina replaced by Clinical Issues
fibrous tissue
• Primary amenorrhea (3rd most common cause after
Turner and müllerian agenesis syndromes)
• Vaginal agenesis • Inguinal hernias at birth (consider CAIS if bilateral)
• Gonadal dysgenesis
t
ne
e.
yn
(Left) Longitudinal US of
the pelvis in a 16-year-old
phenotypic female with
primary amenorrhea and
bg
"lack of development" shows
absent uterus and ovaries.
(Right) Longitudinal US of the
ko
pelvis in the same girl shows
an atretic vagina . Follow-
up genetic testing proved to
be a karyotype of 46,XY in a
oo
phenotypic female.
eb
://
tp
ht
(Left) Transverse US of the

right inguinal canal in a 3-
day-old phenotypic female
presenting with palpable
masses in the inguinal region
shows a soft tissue echogenic
mass corresponding to
undescended testis .
(Right) Transverse US of
the left inguinal canal in
left undescended testis .
Follow-up genetic testing
showed 46,XY karyotype
and complete androgen
insensitivity syndrome.
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ANDROGEN INSENSITIVITY SYNDROME
TERMINOLOGY (receptor-negative) or post-receptor defect (receptor-
positive)
Synonyms ▪ Androgen receptor defect → no response to
• Complete androgen insensitivity syndrome (CAIS), testosterone signal → undermasculinization of
testicular feminization external genitalia in utero and deficient virilization
at puberty
Definitions o Müllerian regression factor produced by testes →
• 46,XY karyotype with female phenotype with absent or rudimentary müllerian structures
functioning testes but end-organ resistance to
androgens
• Genetics
o 46,XY karyotype, X-linked recessive (androgen
o Results in 46,XY "undermasculinized genitalia" and
receptor gene on X chromosome)
phenotypic female
IMAGING • Tan or white nodules within testes corresponding to
hamartomas (60%)
General Features • Cysts of müllerian or wolffian duct origin, located at
• Morphology lateral poles of testes (50%)
o Bilateral undescended testes
▪ Testes located along common or external CLINICAL ISSUES
t
iliac chain (70%), inguinal canal (25%),
ne
retroperitoneum (5%) Presentation
▪ May be associated with indirect inguinal hernias • Most common signs/symptoms
o Cysts (remnants of müllerian or wolffian ducts ) in o Primary amenorrhea (3rd most common cause after
e.
50% of cases Turner and müllerian agenesis syndromes)
o Secondary germ cell tumors in testes (2.5%) o Inguinal hernias at birth (consider CAIS if bilateral)
▪ Most commonly seminoma or gonadoblastoma •
yn
Clinical profile
o Female phenotype at birth and puberty
MR Findings
▪ Normal breast development at puberty due to
• T2WI
o Uterus and upper vagina, replaced by fibrous tissue
bg elevated estrogen secretion from testes
▪ Usually diagnosed in perimenarchal stage with
o Signal intensity of undescended testes is typically
inguinal hernias or with failure to develop menses
lower than normal gonads
ko
• Grayscale ultrasound • Most function as normal sterile females
o Absent or rudimentary uterus, fallopian tube, and • Increased risk of seminoma or gonadoblastoma (2-5%
oo
first 2 decades, 10% after puberty, 30% at 50 years)

upper vagina
o Undescended testes (oval, hypoechoic to echogenic Treatment
structures) • Testes left in situ (as source of estradiol) until
eb
o Secondary germ cell tumors completion of puberty and feminization, with prompt
▪ Hypoechoic to hyperechoic mass with calcification removal thereafter
Imaging Recommendations • Prepubertal inguinal herniorrhaphy
://

o US: Initial method to screen müllerian structures and DIAGNOSTIC CHECKLIST
tp
evaluate inguinal canal

o MR is more accurate for confirming absence of Consider
• Consider CAIS in patients presenting with primary
ht
müllerian structures and location of undescended

testes amenorrhea
• Search for undescended testes in all cases of abnormal
internal genitalia
Vaginal Agenesis SELECTED REFERENCES
• Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome 1. Subramaniam A et al: Androgen insensitivity syndrome: ten
o Absent uterus and upper vagina, normal ovaries years of our experience. Front Biosci (Elite Ed). 5:779-84,
2013
Gonadal Dysgenesis 2. Moshiri M et al: Evaluation and management of disorders of
• Streak gonads, associated with hypoplastic uterus sex development: multidisciplinary approach to a complex
diagnosis. Radiographics. 32(6):1599-618, 2012
3. Chavhan GB et al: Imaging of ambiguous genitalia:
PATHOLOGY classification and diagnostic approach. Radiographics.
28(7):1891-904, 2008
General Features
• Etiology
o Androgen resistance due to absence of receptor
protein, changes in receptor protein structure 7
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Multiorgan Disorders AMBIGUOUS GENITALIA
Key Facts
Terminology o Presence of ovaries, uterus, & fallopian tubes; no
• Disorders of sexual development (DSD); formerly testes
o Virilization of external genitalia
known as female or male pseudohermaphroditism,
true hermaphroditism, and intersex conditions •46,XY DSD ( Male pseudohermaphroditism)
• Includes congenital adrenal hyperplasia (CAH), o Presence of testes, which may be maldescendant or
in scrotum
congenital androgen insensitivity syndrome (CAIS),
and testicular feminization o Absence or rudimentary internal female genital
• Rare condition in which external genitals of infant do tract organs (testes synthesize müllerian-inhibiting
substance)
not appear to be clearly either male or female
o External genitalia completely feminized in testicular
Imaging feminization, with varying degrees of incomplete
• Main role of imaging is to demonstrate anatomy of virilization in other disorders
genitourinary tract, not to determine sex •Ovotesticular DSD (True hermaphroditism)
• Evaluating adrenal glands is necessary to exclude o Refers to histology of a gonad that contains both
congenital adrenal hyperplasia or adrenal neoplasm as ovarian follicles and testicular tubular elements
cause o US plays a key role in detecting gonads
• 46,XX DSD (Female pseudohermaphroditism) o MR is most sensitive modality to visualize ovaries
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and uterus and undescended testes
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image in a 46,XY disorder of
sexual development (DSD)
newborn with no palpable
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testes in the scrotum shows a
hypoplastic uterus as the
dominant internal genitalia.
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image to survey a 46,XY DSD
newborn shows no ovaries but
a small midline uterus as
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the dominant internal genital

organ.
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://
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(Left) Lateral image from a

genitogram in a term infant
with ambiguous genitalia,
perineal hypospadias, and
46,XY DSD shows filling
of the vaginal cavity
and urinary bladder .
(Right) Lateral delayed
image from a genitogram in
the same term infant with
ambiguous genitalia, perineal
hypospadias, and 46,XY DSD
shows more filling of the
vaginal cavity and common
urogenital (UG) sinus .
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AMBIGUOUS GENITALIA
TERMINOLOGY ▪ Müllerian duct structures typically develop on
gonad side(s) not containing testicular tissue
Synonyms ▪ Wolffian duct structures tend to be observed on
• Disorders of sexual development (DSD), formerly gonad side(s) containing functioning testicular
known as female or male pseudohermaphroditism, true tissue
hermaphroditism, and intersex conditions
o Includes: Congenital adrenal hyperplasia (CAH), MR Findings
congenital androgen insensitivity syndrome (CAIS), • Testes and ovaries best imaged on T2WI sequences;
generally high signal intensity on T2WI, with
testicular feminization
intermediate signal intensity on T1WI
Definitions • On T2WI, gonads may have an outer intermediate
• Rare condition in which external genitals of infant do signal intensity rim that distinguishes them from
not appear to be clearly either male or female lymph nodes
• Immature ovaries lack follicles and may be very similar
to small testes or ovotestes
IMAGING
• Dysgenetic gonads may appear as streak gonads,
General Features identified on T2WI as thin, low-intensity stripes
• Best diagnostic clue • Coronal plane helps assess position of a maldescendant
o Discordant appearance of outer genitalia and testis (from abdomen through perineum)
•
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T2WI helps differentiate between penis and
internal genital organs
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o Main role of imaging is to demonstrate anatomy of hypertrophied clitoris
genitourinary tract, not to determine sex Ultrasonographic Findings
o Evaluating adrenal glands is necessary to exclude
• Main purpose of examination is to identify presence or
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congenital adrenal hyperplasia or adrenal neoplasm absence of testes, ovaries, and uterus
as cause • Optimally performed in newborn period when
•
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Location maternal hormones cause uterus and ovaries to be
o Pelvis: Perineum, inguinal canal prominent
o Abdomen: Kidneys and adrenal glands • Assessment of inguinal and perineal regions necessary
• Size
bg to evaluate for ectopic testicular tissue or an ovotestis
o Ovaries, uterus, and testes may be absent, • In normal infants, only 1 ovary detected in ~ 40% and
rudimentary, or fully developed for age neither ovary detected in 16%; thus, nonvisualization
o Congenital adrenal hyperplasia: Enlarged adrenal of an ovary on US does not completely exclude its
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glands, limb length > 20 mm and width > 4 mm in a existence

newborn • 3D US may facilitate intrauterine evaluation of
• Morphology ambiguous genitalia
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o Internal genital organs may include ovaries, testes

or ovotestes, parts of müllerian structures (uterus,
fallopian tubes and upper 1/3 of vagina), or parts of
o US plays a key role in detecting gonads, including
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the wolffian structures (vas deferens, epididymis and

undescended testes
seminal vesicles) in various combinations o MR is most sensitive modality to visualize ovaries and
o May be associated with anomalies of urinary tract
o 46,XX DSD (formerly: Female uterus and to evaluate undescended testes
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o US and MR may also accurately assess associated

pseudohermaphroditism)
anomalies of urinary tract or adrenal gland
▪ Presence of ovaries, uterus, and fallopian tubes,
•
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Protocol advice
with no testes
o US should include abdomen and pelvis to detect
▪ Virilization of external genitalia
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o 46,XY DSD (formerly: Male possible intraabdominal undescended testes or

pseudohermaphroditism) ovotestes, pelvis to detect an immature uterus, and
▪ Presence of testes, which may be maldescendant or inguinal canals and perineum to detect possible
in scrotum cryptorchidism
o MR should include axial and coronal T2WI of
▪ Absence or rudimentary internal female genital
tract organs (testes synthesize müllerian-inhibiting abdomen and pelvis to detect high-signal gonads
o US and MR protocols should include examination of
substance)
▪ External genitalia completely feminized in kidneys, urinary tract, and adrenal glands as well
testicular feminization, with varying degrees Other Modality Findings
incomplete virilization in other disorders
o Ovotesticular DSD (formerly: True hermaphroditism)
• Genitogram (vesicocystourethrogram [VCUG];
vaginogram)
▪ Refers to histology of a gonad that contains both o Establish urinary tract associated anomalies such as a
ovarian follicles and testicular tubular elements common urogenital (UG) sinus
▪ May have testis on 1 side and ovary on the other
▪ Various features of both male and female external
genitalia as well as internal sex organs, dependent
on amount of androgens produced by gonads
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Multiorgan Disorders AMBIGUOUS GENITALIA
o Often unclear
Agenesis of Uterus Natural History & Prognosis
• Most common form is Mayer-Rokitansky-Kuster-Hauser • Ambiguous genitalia is generally not a life-threatening
condition; however, it may cause social problems as
(MRKH) syndrome, which is combined agenesis of
well as infertility
•
uterus, cervix, and upper portion of vagina
Usually normal ovaries, therefore normal female • Determination of true sex of child with genetic testing
may not always be possible
maturation and phenotype, but absence of menses
• Gender may be chosen for child based on external
Cryptorchidism appearance of genitalia or more dominant internal
• Absence of testes in scrotum; normal male phenotype, genital organs
external and internal male genital organs • In CAH, associated mineralocorticoid deficiency may
cause salt wasting, a true medical emergency in the
newborn
PATHOLOGY
• If undescended testes are detected, surgical removal is
General Features advised to prevent development of testicular tumors
o 46,XX DSD
▪ Congenital adrenal hyperplasia in > 80%,
• Treatment combines hormonal manipulation and
cosmetic surgery to achieve desired phenotype
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deficiency in 21-hydroxylase causes inability to
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produce cortisol, with elevated ACTH, resulting in
increased production of 17-hydroxyprogesterone, DIAGNOSTIC CHECKLIST
progestins, and androgen precursors Consider
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▪ Additional rare causes: Maternal drug ingestion
(synthetic progestins) during 1st trimester of
• Are there palpable testes in the scrotum? If so,
karyotype is almost definitely XY
• When female karyotype with masculinization is
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pregnancy and adrenal or ovarian androgen-
producing tumors (very rare) present, check adrenal glands for hyperplasia
o 46,XY DSD
▪ Inability of testes to respond to gonadotropin Image Interpretation Pearls
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stimulation • Role of imaging is to define anatomy of genital organs
▪ Congenital errors in biosynthesis of testosterone and urinary tract, not to determine sex
or inability to convert testosterone to • US and MR play an important role in identifying
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dihydrotestosterone gonads and internal sex organs

▪ Androgen insensitivity of target organs, a.k.a. CAIS • Basic evaluation includes identifying absence or
or testicular feminization presence of ovaries, testes, uterus, and vagina
• Testes and ovotestes may be located anywhere from
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o Ovotesticular DSD
▪ Dysgenetic gonad development abdomen down to perineum
• Genetics • Recommend T2WI thin-section axial, coronal, and
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o 46,XX DSD: Karyotype 46,XX sagittal imaging from abdomen through perineum
o 46,XY DSD: Karyotype 46,XY
o Ovotesticular DSD : Karyotype is 46,XX in 80%,
SELECTED REFERENCES
://
46,XY in 10%, and mosaic in 10%

o Ovotesticular DSD is most likely intersex state after 1. Nakhal RS et al: Evaluation of retained testes in adolescent
girls and women with complete androgen insensitivity
CAH in a 46,XX child
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• Associated abnormalities 2.
syndrome. Radiology. 268(1):153-60, 2013
Nezzo M et al: Role of imaging in the diagnosis and
o Congenital abnormalities of kidneys and urinary management of complete androgen insensitivity syndrome
ht
tract in adults. Case Rep Radiol. 2013:158484, 2013

3. Mansour SM et al: Does MRI add to ultrasound in the
assessment of disorders of sex development? Eur J Radiol.
CLINICAL ISSUES 81(9):2403-10, 2012
4. Moshiri M et al: Evaluation and management of disorders of
Presentation
sex development: multidisciplinary approach to a complex
diagnosis. Radiographics. 32(6):1599-618, 2012
o External appearance varies between genetically 5. Chavhan GB et al: Imaging of ambiguous genitalia:
defined XX newborns and XY newborns classification and diagnostic approach. Radiographics.
o May be evident in newborn or detected later in life 28(7):1891-904, 2008
6. Hughes IA et al: Consequences of the ESPE/LWPES
presenting as delayed menarche or infertility
guidelines for diagnosis and treatment of disorders of
sex development. Best Pract Res Clin Endocrinol Metab.
o Salt wasting in a newborn may be associated with 21(3):351-65, 2007
CAH and 46,XX DSD 7. Nabhan ZM et al: Disorders of sex development. Curr Opin
Obstet Gynecol. 19(5):440-5, 2007
Demographics 8. Hughes IA et al: Consensus statement on management of
• Age intersex disorders. Arch Dis Child. 91(7):554-63, 2006
o Most commonly diagnosed in newborns
7 • Gender
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AMBIGUOUS GENITALIA
image in a child with ambiguous
genitalia shows absence of the
normal uterus between the
bladder and rectum . (Right)
Longitudinal ultrasound image in
a child with ambiguous genitalia
shows absence of the normal
uterus between the bladder and
rectum .
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image of the right labia in a
newborn with 46,XX female
bg karyotype and ambiguous
genitalia with enlarged labia
shows a round echogenic
mass , corresponding to an
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undescended right testis. (Right)

Transverse ultrasound image
of the left labia in a newborn
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with 46,XX female karyotype

and ambiguous genitalia
shows a round echogenic
mass, corresponding to an
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undescended left testis.

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(Left) Sagittal image from a

genitogram in a 5-month-old
46,XY karyotype baby presenting
with ambiguous genitalia and
enlarged labia shows filling
of the vaginal cavity , and
communication with a female-
type urethra by a common
urogenital sinus . (Right) AP
view from a genitogram in a
46,XX baby with prior history of
removal of undescended inguinal
gonads, ambiguous genitalia, and
21-hydroxylase congenial adrenal
hyperplasia shows filling of the
vagina and fallopian tubes
.
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Multiorgan Disorders GONADAL DYSGENESIS
Key Facts
Terminology • Germ cell tumors
• Disorder of sexual development • US is best modality in newborn due to prominence of
• Range of abnormalities of gonads and internal uterus and ovaries due to maternal hormones
• Mainly for identification of müllerian structures
genitalia with variable karyotypes
• Replacement of gonads (testes or ovaries) by fibrous Top Differential Diagnoses
tissue, devoid of germ cells
• 45,X Turner syndrome: Most common karyotype • Androgen insensitivity syndrome
(50%) • Other disorders of intersexuality
• Hypogonadotropic hypogonadism (HH)
Imaging
• Unilateral or bilateral streak gonads: 2-3 cm long and Pathology
0.5 cm wide • Most common Turner karyotypes 45,XO (50%), and
• Müllerian structures typically present but typically mosaicism ("mixed") 45,XO and 46,XX (15-20%)
hypoplastic Clinical Issues
• Streak gonads slightly hypointense or isointense • Amenorrhea with normal external genitalia
• Significant risk of malignant transformation (30%) in
relative to muscle on T1WI
• Testes, typically undescended, ranging from slightly
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hypointense to slightly hyperintense relative to muscle gonad in presence of Y chromosome
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image in a newborn with
mixed gonadal dysgenesis
shows small, round,
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hypoechoic structures in the
right and left pelvis suggestive
of streak ovaries . (Right)
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Longitudinal ultrasound
image in a patient with mixed
gonadal dysgenesis shows a
hypoplastic vagina with no
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distinct uterus.
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image of a newborn with
shows a hypoplastic vagina
and uterus . (Right) Coronal
T1WI C+ FS MR of a girl with
shows a hypoplastic midline
uterus and streak-like left
ovary .
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GONADAL DYSGENESIS
o Testes ranging from slightly hypointense to slightly
TERMINOLOGY
hyperintense relative to muscle
Abbreviations • T2WI
• Gonadal dysgenesis (GD) o Streak gonads: 2-3 cm long and 0.5 cm wide
▪ Hypointense to signal of normal gonads
Synonyms ▪ Isointense or slightly hyperintense to muscle
• Disorder of sexual development ▪ Typically located in broad ligament
Definitions ▪ Correctly identified in 40-65% (limited data)
o Testes
• Replacement of gonads (testes or ovaries) by fibrous ▪ Typically undescended
tissue, devoid of germ cells
▪ Hypointense to signal of normal gonads
• Range of abnormalities of gonads and internal genitalia ▪ Hyperintense to muscle, hypointense relative to fat
with variable karyotypes
o 45,X Turner syndrome: Most common karyotype ▪ Low SI rim on T2WI helpful in distinction from
(50%) lymph nodes
o 46,XX "pure" GD ▪ Correctly identified in 55-80% (limited data)
o 46,XY "complete" GD including o Hypoplastic uterus
▪ 46,XY embryonic testicular regression (ETR) ▪ Junctional zone anatomy more easily seen in
▪ 46,XY bilateral vanishing testes syndrome (BVTS) neonate or after exogenous hormonal stimulation
o 45,XO/46,XY mosaic ("mixed") GD ▪ Thin endometrial complex with high signal
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• intensity (SI)
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Confusing use of terms "pure" and "complete" in
literature; best replaced by specification of karyotype ▪ Hypointense myometrium
▪ Uterus correctly identified in 93% (limited data)
o Germ cell tumors
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IMAGING ▪ Signal dependent on histological type and
background signal of gonad
General Features ▪ High SI masses or enlargement of dysgenetic
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• Best diagnostic clue gonads should raise suspicion for secondary
o Unilateral or bilateral streak gonads: 2-3 cm long and
malignancy
0.5 cm wide
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o Müllerian structures typically present but typically Ultrasonographic Findings
hypoplastic • Grayscale ultrasound
• Gonads o Best modality in newborn due to prominence of
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o Bilateral streak gonads uterus and ovaries due to maternal hormones

▪ 45,X Turner syndrome, 46,XX "pure" GD, and o Mainly for identification of müllerian structures
46,XY "complete" GD ▪ Hypoplastic prepubertal uterus
▪ Endometrial stripe frequently not visualized
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o Asymmetric combinations of streak gonads and

dysgenetic gonads o Streak gonads difficult to visualize
▪ Unique to 45,XO/46,XY mosaic GD o Undescended testes most often visualized when
o No gonads (neither testes nor ovaries)
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located in inguinal canal

▪ Unique to 46,XY ETR-BVTS ▪ Echogenic mass in ectopic gonads suspicious for
• Müllerian structures gonadoblastoma (frequent calcification)
o Present but hypoplastic
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▪ 45,X Turner syndrome, 46,XX "pure" GD
▪ Uterine corpus/cervix ratio 1:1
o US
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▪ Thin atrophic endometrium

▪ Screening for presence of müllerian derivatives,
▪ Atrophic vagina
o Well-developed müllerian structures undescended testes in inguinal canal, renal
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anomalies
▪ 46,XY "complete" GD and BVTS o MR
o Asymmetric internal genitalia
▪ To locate streak gonads and undescended testes
▪ Unique to 45,XO/46,XY mosaic GD
▪ To document presence of müllerian structures
▪ Unilateral müllerian ducts (unicornuate uterus) o Genitogram (VGUG; vaginogram)
with contralateral wolffian structures
▪ Demonstrate common urogenital sinus
o Absent internal genitalia
▪ Communicates with urethra and vaginal cavity
▪ Unique to 46,XY ETR
• Protocol advice
CT Findings o MR: Phased-array body coil
• CECT o High-resolution T1WI and FSE T2WI
o Not well-suited to evaluate müllerian derivatives or ▪ Transverse, sagittal, and coronal images
identification of gonads
MR Findings DIFFERENTIAL DIAGNOSIS
• T1WI
Androgen Insensitivity Syndrome
o Streak gonads slightly hypointense or isointense
• 46,XY karyotype with female phenotype
relative to muscle on T1WI
• Bilateral undescended testes 7
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Multiorgan Disorders GONADAL DYSGENESIS
• Vaginal agenesis o Devoid of oocytes, otherwise indistinguishable from

normal ovarian stroma
Other Disorders of Intersexuality
• Dysgenetic testes composed of immature hypoplastic
• Chromosomal and biochemical profile needed for seminiferous tubules and persistent stroma resembling
differentiation among various entities that of streak gonads
Hypogonadotropic Hypogonadism (HH) o Testes lack germinal elements: Infertile patients
• Kallmann syndrome (anosmia) associated with • Rudimentary cords without recognizable testicular
hypogonadism tissue in ETR and BVTS
• Normal prepubertal gonads/internal genitalia
CLINICAL ISSUES
PATHOLOGY Presentation
o Amenorrhea with normal external genitalia
• Genetics
o Turner syndrome most common (50%) • 45,X (Turner syndrome)
▪ Most common Turner karyotypes 45,XO (50%) and o 4 classic features: Female phenotype, short stature,
46,XX (15-20%) absence of secondary sexual characteristics, somatic
• Associated abnormalities abnormalities (protean manifestations)
o Persistent infantile external genitalia at puberty
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o Deficient müllerian regression due to inadequate
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müllerian inhibitory substance from dysgenetic testis Demographics
• Lack of normal endometrial and myometrial definition • Epidemiology
with streak ovaries due to lack of estrogen o Turner syndrome: 1 in 2,500 live births
•
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Associated abnormalities with Turner syndrome
o Coarctation of aorta, renal anomalies Natural History & Prognosis
• No reproductive potential
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• Significant risk of malignant transformation (30%) in
• 46,X (Turner syndrome) gonad in presence of Y chromosome
o Female external genitalia o Usually in first 2 decades of life
o Bilateral streak gonads, (white, fibrous structures),
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o Gonadoblastoma most common and frequently
typically in broad ligament bilateral, followed by dysgerminoma or seminoma
o Hypoplastic prepubertal uterus/vagina
• Treatment
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46,XX (pure) gonadal dysgenesis
o Closely related to Turner syndrome • Removal of gonads mandatory in all patients with
o Lacks somatic stigmata of Turner syndrome, with GD 46,XY gonadal dysgenesis
• Sex assignment based on external genitalia
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only, hence the term "pure”

• 46,XY (complete) GD
o Complete absence of testicular differentiation, DIAGNOSTIC CHECKLIST
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complete failure to masculinize

o Female external genitalia with bilateral streak Consider
gonads • Consider gonadal dysgenesis in patients with primary
o Well-developed müllerian structures amenorrhea
://
• 46,XY ETR and BVTS

o Represent a variant of 46,XY (complete) GD
• Secondary malignancy with high SI in dysgenetic
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o Phenotype spectrum from complete female to

gonads
normal male, dependent on timing of testicular loss
o Absent gonads common feature of all forms
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• 45,XO/46,XY mosaic (mixed) GD SELECTED REFERENCES

o Phenotype ranging from female with Turner 1. Moriya K et al: Impact of laparoscopy for diagnosis and
syndrome (25%) to those with predominantly male treatment in patients with disorders of sex development. J
ambiguous genitalia (70%), rarely normal male Pediatr Urol. Epub ahead of print, 2014
phenotype 2. Kumar J et al: Managing disorder of sexual development
o Similar spectrum in gonadal differentiation: Bilateral surgically: A single center experience. Indian J Urol.
28(3):286-91, 2012
streak gonads to asymmetric combinations of streak
3. Moshiri M et al: Evaluation and management of disorders of
gonads sex development: multidisciplinary approach to a complex
▪ Dysgenetic/streak gonad associated with ipsilateral diagnosis. Radiographics. 32(6):1599-618, 2012
müllerian derivatives (unicornuate uterus, 4. Ocal G et al: The clinical and genetic heterogeneity of mixed
fallopian tube) gonadal dysgenesis: does "disorders of sexual development
▪ Well-differentiated testes with functional Sertoli (DSD)" classification based on new Chicago consensus cover
and Leydig cells with ipsilateral wolffian ducts but all sex chromosome DSD? Eur J Pediatr. 171(10):1497-502,
no müllerian ducts 2012
5. Steven M et al: Laparoscopy versus ultrasonography for
Microscopic Features the evaluation of Mullerian structures in children with
• Streak ovaries: Interlacing waves of dense fibrous complex disorders of sex development. Pediatr Surg Int.
7 stroma 28(12):1161-4, 2012
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GONADAL DYSGENESIS
of a girl with mixed gonadal
dysgenesis shows a hypoplastic
vaginal cavity and uterus .
(Right) Coronal T2WI FSE MR
of a girl with complete gonadal
dysgenesis shows absence of
müllerian structures. A streak T2-
bright structure in left pelvis
correlates to a streak left ovary.
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MR of a patient with mixed
gonadal dysgenesis shows a
bg hypoplastic midline uterus
and small, streak-like left ovary
. (Right) coronal T1WI C+ FS
MR in the same girl with mixed
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gonadal dysgenesis shows the

T2-hyperintense streak-like left
ovary and hypoplastic uterus
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.
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://
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(Left) Sagittal image from a

genitogram of a 46,XY male
karyotype disorder of sexual
development newborn shows
a common urogenital sinus
channel communicating with the
vagina and female urethra
. (Right) Sagittal image from
a genitogram performed in a
newborn with 46,XY karyotype
DSD and common urogenital
sinus shows filling of both the
female urethra and vaginal
cavity .
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SECTION 8
Pelvic Floor
Overview
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Overview of the Pelvic Floor 8-2
Pelvic Floor Imaging 8-30
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Pelvic Floor Dysfunction
Anterior Compartment
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Overview of the Anterior Compartment 8-40
Anterior Compartment Imaging 8-60
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Middle Compartment
Overview of the Middle Compartment 8-68
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Middle Compartment Imaging 8-80

Posterior Compartment
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Overview of the Posterior Compartment 8-88

Imaging of Fecal Incontinence 8-102
Imaging of Obstructed Defecation 8-112
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Multicompartmental
Multicompartmental Imaging 8-126
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Pelvic Floor OVERVIEW OF THE PELVIC FLOOR
◦ Pubic bones meet in midline at fibrocartilaginous

TERMINOLOGY junction
Abbreviations ◦ Bones connected by 2 ligaments and interpubic disc
• ▪ Superior pubic ligaments: Connects bones above,
Arcus tendineus levator ani (ATLA)
• Arcus tendineus fascia pelvis (ATFP) extending to pubic tubercle
▪ Arcuate pubic ligament: Thick arch of fibers
APPROACHES FOR FUNCTIONAL connecting lower borders of symphyseal pubic

surface bounding pubic arch
DESCRIPTION OF PELVIC FLOOR ▪ Interpubic disc: Connects medial pubic surfaces
▪ Each articular surface is covered by thin layer of
Classic 3-Compartment Approach
• Divides pelvic floor into 3 major compartments tightly adherent hyaline cartilage
• Pelvis is divided into 2 parts by pelvic brim
◦ Anterior: Includes urinary bladder, urethra, and
◦ False pelvis above forms part of abdominal cavity
urethral support system
◦ True pelvis below pelvic brim
◦ Middle: Includes vagina (anterior and posterior wall)
and uterocervical support Functional Correlation of Bony Pelvis
◦ Posterior: Contains rectum and supporting • Scaffolding for pelvic floor
structures ◦ Numerous tuberosities, indentations, spines, and
• Patients with abnormalities in 1 compartment often ridges all serve as attachment sites for various
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have disorders in another muscles, ligaments, and pelvic fascia
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• Arcuate pubic ligament serves as reference point in
Active and Passive Conceptual Approach
• Pelvic floor components are divided into passive and MR imaging of urethral supporting ligaments
active structures
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◦ Passive structures PELVIC WALL
▪ Pelvic bones
Anterior
▪ Supportive connective tissue
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• Formed by posterior surfaces of bodies of pubic bone,
◦ Active structures
symphysis pubis, and pubic rami
▪ Pelvic floor muscles
• Shallowest wall
• This classification cannot precisely explain
bg
pathogenesis of various dysfunctions Posterior
• Formed by coccyx and sacrum, piriformis muscles, and
Multilayered System Approach their covering parietal pelvic fascia
ko
• Considers passive and active components of pelvic floor • Deepest wall
as integrated multilayer system, organized from cranial
to caudal Lateral
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◦ 1st layer: Endopelvic fascia • Ilium and ischium

◦ 2nd layer: Pelvic diaphragm • Obturator internus muscle and its covering fascia,
◦ 3rd layer: Urogenital diaphragm obturator membrane
◦ 4th layer: Superficial external genital muscles ◦ Obturator foramen is covered by a membrane,
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except for obturator canal, which is positioned in

Functional 3-Part Pelvic Supporting Systems superolateral aspect of foramen
Approach ▪ Obturator vessels and nerve pass through this
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• New, more function-based classification of pelvic opening

floor support system • Sacrotuberous ligaments and sacrospinous ligaments
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• Based on fact that each passive and active structural ◦ Functionally, both ligaments fix lower end of sacrum
component of pelvic floor plays a role in and coccyx, preventing upward rotation at sacroiliac
◦ Urinary and fecal continence joint by weight of body
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◦ Supporting pelvic organs and preventing pelvic organ ◦ Sacrotuberous ligament

prolapse ▪ Extends from lateral part of sacrum, coccyx, and
• In this approach, all structures that contribute to same posterior inferior iliac spine and inserts into ischial
function are grouped under 1 system tuberosity
◦ Urethral support system ▪ Forms posterior boundary of lesser sciatic foramen
▪ Structures that maintain urinary continence ▪ Strong ligament
◦ Vaginal support system ◦ Sacrospinous ligament
▪ Supporting elements that prevent prolapse ▪ Triangular in shape
◦ Maintenance of anal continence ▪ Base is attached to lateral part of sacrum and
▪ Supporting elements and anal sphincter complex coccyx and its apex attaches to spine of ischium
BONY PELVIS PELVIC DIAPHRAGM

Osseous Structures Definition
• 2 iliac bones form lateral and anterior walls • Formed by coccygeus and levator ani muscles
• Sacrum and coccyx form back wall ◦ Acts as a shelf to support pelvic organs
• Pubic symphysis
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OVERVIEW OF THE PELVIC FLOOR
Pelvic Floor
▪ Augmenting resistance to pressure by closing
COCCYGEUS MUSCLE uterovaginal angle
Anatomy and Function ▪ Obstructing pelvic outlet by compressing vaginal
• Shelf-like musculotendinous structure canal
• • Levator ani muscle has 2 types of striated muscle fibers
Forms posterior part of pelvic diaphragm
◦ Coccygeus is not part of levator ani, having different ◦ Type I fibers
▪ Slow tonic fibers
function and origin
◦ Proportions of muscular and ligamentous parts may ▪ Constitute majority of levator ani muscle fibers to
vary maintain constant tone

◦ Origin ◦ Type II fibers
▪ Arises from tip of ischial spine along posterior ▪ Fast phasic muscle fibers
▪ Increased density of these fast phasic muscle fibers
margin of internal obturator muscle
◦ Insertion in perianal and periurethral portions of levator ani
▪ From site of origin, fibers fan out and insert into ▪ Responsible for rapid reaction to sudden pressure
lateral side of coccyx and lowest part of sacrum changes (stress events) such as those generated by a
▪ Sacrospinous ligament lies along posterior edge of cough or sneeze
coccygeus muscle to which the ligament is fused
MR ANATOMY OF PUBORECTALIS MUSCLE
LEVATOR ANI MUSCLE
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Topographic MR Anatomy
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Components • Relationship between puborectalis and pubococcygeus
• ◦ On sagittal images, pubococcygeus and puborectalis
Levator ani has been divided anatomically into 3
components (differentiated according to orgin and muscles are essentially continuous
e.
▪ Can be differentiated by their location and
direction of fiber bundles)
◦ Puborectalis muscle orientation, with pubococcygeus inferior and more
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▪ Arises from superior and inferior pubic rami obliquely oriented
▪ Unites with contralateral puborectalis muscle ◦ On axial images, they are fused to caudal vagina just
posterior to rectum, forming a sling above level of symphysis pubis

▪ Does not insert onto any skeletal structure ▪ At more cephalad level, space exists between
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◦ Pubococcygeus muscle puborectalis and vagina
▪ Arises from back of pubic bone and anterior part of • Relationship between puborectalis and pelvic organs
◦ Puborectalis acts like a sling encasing urethra, vagina,
obturator fascia
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▪ Inserts into lateral aspect of coccyx and rectum

◦ Iliococcygeus muscle ▪ Puborectalis muscle has no attachment to bladder
▪ Arises from fascia overlying obturator internus neck but its anterior portion lies in close proximity
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▪ Inserts into lateral aspect of coccyx, overlapping to mid and lower urethra
• Relationship between puborectalis and external anal
with fibers of pubococcygeus muscle in a staggered
arrangement sphincter
◦ On sagittal images, puborectalis is immediately
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Innervation superior to deep external anal sphincter

• Levator ani nerve ▪ Puborectalis has no skeletal attachment while
◦ Originates from S3, S4, &/or S5 deep portion of sphincter ani externus is indirectly
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◦ Innervates both coccygeus and levator ani muscle affixed to coccyx by fibers of anococcygeal
complex ligament
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◦ Occasionally, separate nerve comes directly from S5

to innervate puborectalis muscle Parameters Measured
◦ Pathway • Puborectalis muscle is often thinner on right side than
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▪ After exiting sacral foramina, travels 2-3 cm medial left when measured in axial plane
◦ Mean thickness of left puborectalis muscle is 6.5 mm
to ischial spine and arcus tendinous levator ani
across coccygeus, iliococcygeus, pubococcygeus, (SD: 2.04)
◦ Mean thickness of right puborectalis muscle is 4.9
and puborectalis
◦ Injury of levator ani nerve mm (SD: 2.3)
▪ Given its location, levator ani nerve is susceptible ◦ Whether this asymmetry can be totally attributed to
to injury from parturition or pelvic surgery chemical shift alone is not confirmed
▪ Fixation points used in sacrospinous ligament
Movement of Puborectalis Muscle
fixation and iliococcygeus vaginal vault • Assessed during withholding in sagittal plane
suspensions are in close proximity to course of ◦ During withholding, puborectalis muscle moves
levator ani nerve dorsoventrally to narrow urogenital hiatus
Functional Correlation • Urogenital hiatus: Opening within levator ani muscle
• Levator ani muscle works at rest and during stress to through which urethra, vagina, and rectum pass (and
counteract intraabdominal pressure through which prolapse occurs)
◦ Can diminish forces of intraabdominal pressure upon ◦ Bounded ventrally by pubic bones and laterally by
pelvic contents by puborectalis muscle

▪ Deflecting direction of intraabdominal pressure
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▪ At level of anal canal, obtained by drawing line

Functional Correlation of Puborectalis
between origin of iliococcygeus muscle slings from
Muscle obturator internus
• Pelvic organ support ▪ Posteriorly, between margins of ischium
◦ Direct support for rectum
• Slope of iliococcygeus muscle
◦ Indirect support to vagina, bladder, and urethra by
◦ Has medial slant and cranial convexity
drawing these structures ventrally toward pubic bone ◦ Slope is measured by iliococcygeus angle
◦ Traction force contributes to
▪ Iliococcygeus angle decreases progressively as one
▪ More acute anorectal angle (and thus anal canal is
moves from anterior to posterior coronal sections
closed) ▪ Posterior iliococcygeus muscle is more horizontally
▪ Posterior curve to vagina and horizontal levator
oriented as it extends posteromedially to attach to
plate the midline anococcygeal raphe and coccyx
• Urethral pressure
◦ Puborectalis muscle aids in maintaining urethral Movement of Iliococcygeus Muscle
pressure • Assessed during straining in coronal plane
▪ Some of its anteromedial fibers attach to vagina ◦ During straining, there is descent of iliococcygeus
and may assist in direct elevation and support muscle, which assumes a more vertical orientation
of urethrovesical neck, thus affecting urethral ▪ Posterior part descends more than anterior part
pressure and continence ◦ During straining, there might be increase in muscle
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◦ Functionally, it is hypothesized that weakness of thickness
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puborectalis contributes to problems with urinary
continence
Functional Correlation of Iliococcygeus
Muscle
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MR ANATOMY OF • Stretches in horizontal plane from rectal hiatus to
ILIOCOCCYGEUS MUSCLE coccygeus muscle, where upper 1/3 of vagina and cervix
lie upon it
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Topographic MR Anatomy ◦ This horizontal part assists in development and
• Sagittal plane maintenance of vaginal axis
◦ Iliococcygeus muscle is best seen in off-midline ◦ Active at rest and contracts further during rectus
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sagittal plane abdominis contraction to maintain proper vaginal
▪ Origin of iliococcygeus is visible arising from fascia axis
overlying obturator internus • Functionally, it is hypothesized that weakness of
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• Axial plane iliococcygeus muscle contributes to vaginal prolapse

◦ Location of arcus tendineus levator ani (origin of
iliococcygeus muscle) is best seen in axial plane MR ANATOMY OF LEVATOR PLATE
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◦ Muscle itself is best seen in more cephalad axial

planes
• Main part of levator ani muscle seen on sagittal MR
• Coronal plane
◦ Origin of iliococcygeus can be clearly visible from images is levator plate
eb
◦ Formed by fusion of right and left iliococcygeus

fascia overlying obturator internus
▪ Fibrofatty tissue separates muscle bundles at their muscle slings in midline
• In normal asymptomatic volunteers, levator plate forms
origin
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▪ Fibrofatty tissue appears as gaps on coronal sections horizontal shelf that supports pelvic organs
and should not be mistaken for defect Parameters Measured
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◦ Relationship of pelvic floor muscles to perineal • Levator plate angle, measured in sagittal plane
membrane is seen in coronal images ◦ Angle measured between pubococcygeal line (PCL)
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Parameters Measured and levator plate axis

◦ During straining, levator plate becomes vertical
• Thickness of iliococcygeus muscle is measured in
▪ Decreases by ~ 16-22° from resting position
coronal sections at level of ischial tuberosity
◦ Measured at midpoint of muscle sling at rest and Movement of Levator Plate
during straining • Evaluated during withholding in sagittal plane
◦ Significant ↑ in muscle thickness occurs on straining ◦ Levator plate contracts by combination of squeeze
▪ Mean thickness at rest: 2.9 mm (SD: 0.82) and inward lift
▪ Mean thickness during straining: 3.9 mm (SD: ▪ Movement reflects multicomponent action of
0.89) levator ani where puborectalis provides inward
• Iliococcygeus angle is measured on coronal plane squeeze and iliococcygeus provides upward lift
between iliococcygeus muscle sling and transverse
plane of pelvis (normal 33.4° ± 8.3° ) SUPPORTIVE CONNECTIVE TISSUE
◦ Transverse plane of pelvis is obtained by drawing line
between corresponding bony landmarks on pelvic Anatomy and Functional Correlation
sidewall • Complex network of connective tissue
▪ Anteriorly, plotted between upper edges of femoral ◦ Composed of collagen, fibroblasts, elastin, smooth
heads muscle cells, and neurovascular and fibrovascular
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Pelvic Floor
▪ Ligaments: Forms well-defined layer composed of ◦ Corresponds to region of vagina that extends from
specialized aggregation of connective tissue introitus to 2-3 cm above hymenal ring
▪ Endopelvic fascia: Forms diffuse layer that consists ▪ Near introitus, vagina is fused laterally to levator
of less well-defined connective tissue ani
◦ Important for passive support of visceral organs and ▪ Posteriorly, attached to perineal body
pelvic floor ▪ Anteriorly, blends with urethra
◦ At this level, there is no intervening paracolpium
Endopelvic Fascia between vagina and adjacent structures, as opposed
• Continuous adventitial layer covering pelvic diaphragm to levels I and II
and viscera ◦ Functional significance
• Expansive membrane is covered by parietal peritoneum ▪ Provides urethral support, having special
• Structure varies considerably in different areas of pelvis importance to urinary continence
◦ e.g., cardinal ligaments are more fibrous, fascia
▪ Endopelvic fascia at this level is better developed
around rectal pillars is less vascular than at more superior levels
• Functional correlation ▪ Therefore, level III provides better support for
◦ Envelops pelvic organs, including parametrium and
vesical neck than higher levels
paracolpium, giving support to uterus and upper ▪ Loss of this normal support at vesical neck may
vagina, respectively result in stress urinary incontinence
Ligaments
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PELVIC FLOOR MUSCLE AND
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• Arcus tendineus levator ani (ATLA) and arcus tendineus
fascia pelvis (ATFP) ENDOPELVIC FASCIAL INTERACTION
◦ Dense, obliquely oriented linear pure connective
tissue structures at pelvic sidewall Normal
e.
▪ Have well-organized fibrous collagen • Muscles give active support of pelvic floor, whereas
▪ Histologically akin to tendons and ligaments of ligaments give passive support to hold pelvic organs in
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peripheral musculoskeletal system place
• ATLA • When levator ani muscles function properly
◦ Condensation of obturator fascia ◦ Pelvic floor is closed
◦ Ligaments and fasciae are under no tension
▪ Majority of levator ani muscle arises from obturator
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fascia ◦ Fasciae simply act to stabilize pelvic organs in their
▪ Provides anchoring sites for active support of pelvic position above levator ani muscle
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floor (puborectalis and iliococcygeus muscles) Abnormal
• ATFP • When pelvic muscles relax or are damaged, ligaments
◦ Posterior 1/2 joins with arcus tendineus levator ani
are put under strain
◦ Provides lateral anchoring sites for anterior vaginal
oo
◦ Pelvic organs lie between high abdominal pressure

wall that underlies and supports urethra
and low atmospheric pressure
Levels of Vaginal Support ◦ In this situation, pelvic organs must be held in place
eb
• Paracolpium, supporting soft tissues that attach upper by ligaments

vagina to pelvic walls, can be divided into 3 levels ◦ Ligaments can sustain these loads for short periods
• Level I (suspension) ◦ If damaged pelvic floor muscles cannot close levator
◦ Upper portion of vagina adjacent to cervix (cephalic hiatus, connective tissues must support pelvic organs
://
2-3 cm of vagina) for extended periods

◦ Suspended from above by relatively long connective ◦ Connective tissue will eventually fail to hold vagina
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tissue fibers of upper paracolpium and other pelvic organs in place

◦ Functional significance
▪ Provides upper vaginal support UROGENITAL DIAPHRAGM
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• Level II (attachment) (PERINEAL MEMBRANE)

◦ Midportion of vagina
◦ At this level, paracolpium becomes shorter Location and Description
◦ Attaches vaginal wall more directly to arcus • Cavity of pelvis is divided by pelvic diaphragm into
tendineus fascia pelvis main pelvic cavity above and perineum below
◦ Stretches vagina transversely between bladder and • Fibromuscular layer directly below pelvic diaphragm is
rectum also called urogenital diaphragm
◦ Pubocervical fascia is composed of anterior vaginal • Triangular in shape
wall and its attachment to pelvic wall through • Spans anterior pelvic outlet and is attached to pubic
endopelvic fascia at this level bones
▪ Provides urinary bladder support • Structures crossing urogenital diaphragm
◦ Similarly, posterior vaginal wall and endopelvic fascia ◦ Females: Crossed by urethra and vagina; membrane is
(rectovaginal) support rectum attached medially to lateral vaginal walls
▪ Forms restraining layer that prevents rectum ◦ Males: Continuous sheet
from protruding forward, blocking formation of a • Trilaminar structure
rectocele ◦ Classically, urogenital diaphragm is described as
• Level III (fusion) trilaminar structure, which includes
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▪ Deep transverse perineal muscles ▪ From site of origin, courses along vestibule and
▪ Superior and inferior fascia inserts on perineal body
▪ Perineal muscle, which is sandwiched between • Ischiocavernosus muscle
superior and inferior fascia ◦ Location and attachment
• Perineal body ▪ Originates from clitoris on each side
◦ Fascial condensation posterior to vagina ▪ Covers crus of clitoris, then has a posterolateral
◦ Insertion site of perineal muscle and external anal course and terminates at ischiopubic ramus
sphincter
Functional Correlation
• Superficial transverse perineal muscles
PERINEUM ◦ Supportive to inferior pelvic wall
Location and Description • Bulbospongiosus and ischiocavernosus
• Perineum is superficial soft tissues below pelvic ◦ Play a role in sexual function
diaphragm ◦ Both muscles compress venous return of clitoris and
• When seen from below with thighs abducted, crus of clitoris, leading to erection
perineum is diamond-shaped
◦ Bounded anteriorly by symphysis pubis
◦ Bounded posteriorly by tip of coccyx
RELATED REFERENCES
◦ Bounded laterally by ischial tuberosities 1. Farouk El Sayed R: The urogynecological side of pelvic floor
t
MRI: the clinician's needs and the radiologist's role. Abdom
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Divisions Imaging. 38(5):912-29, 2013
• Perineum is divided by arbitrary line between ischial 2. Petros P et al: Reconstructive Pelvic Floor Surgery According
to the Integral Theory. In Petros P et al: The Female Pelvic
tuberosities into
◦ Urogenital triangle anteriorly
Floor: Function, Dysfunction and Management According
e.
to the Integral Theory. 2nd ed. Berlin: Springer, 2007
◦ Anal triangle posteriorly
3. Delancey J et al: Functional Anatomy of the Pelvic Floor.
Urogenital Triangle In Bartram C et al: Imaging Pelvic Floor Disorders. 1st ed.
yn
Berlin: Springer, 2003
• Bounded anteriorly by pubic bone and pubic arch 4. Fielding JR: Practical MR imaging of female pelvic floor
• Bounded laterally by ischial tuberosities weakness. Radiographics. 22(2):295-304, 2002
• Contents
bg
5. Singh K et al: Magnetic resonance imaging of normal levator
◦ Urethra ani anatomy and function. Obstet Gynecol. 99(3):433-8,
◦ Vagina 2002
◦ Perineal membrane 6. Bø K et al: Dynamic MRI of the pelvic floor muscles in an
ko
◦ External genital muscles upright sitting position. Neurourol Urodyn. 20(2):167-74,

2001
Anal Triangle 7. Shafik A: Levator ani muscle: new physioanatomical aspects
oo
• Anterior boundary is formed by arbitrary line drawn and role in the micturition mechanism. World J Urol.
between ischial tuberosities 17(5):266-73, 1999
•
8. Tunn R et al: Static magnetic resonance imaging of the
Bounded posteriorly by tip of coccyx
pelvic floor muscle morphology in women with stress
•
eb
Lateral boundaries urinary incontinence and pelvic prolapse. Neurourol

◦ Ischial tuberosities and sacrotuberous ligament
Urodyn. 17(6):579-89, 1998
◦ Overlapped by border of gluteus maximums muscle 9. Fröhlich B et al: Tomographical anatomy of the pelvis,
• Contents pelvic floor, and related structures. Clin Anat. 10(4):223-30,
://
◦ Anus lies in midline 1997

◦ Ischiorectal fossa on either side 10. Strohbehn K et al: Magnetic resonance imaging of the
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levator ani with anatomic correlation. Obstet Gynecol.

87(2):277-85, 1996
SUPERFICIAL EXTERNAL GENITAL MUSCLES 11. Klutke CG et al: Functional female pelvic anatomy. Urol Clin
ht
Location North Am. 22(3):487-98, 1995

•
12. Goodrich MA et al: Magnetic resonance imaging of pelvic
Most superficial of 4 layers of pelvic floor (inferior floor relaxation: dynamic analysis and evaluation of
pelvic wall) are external genital muscles patients before and after surgical repair. Obstet Gynecol.
◦ Includes superficial transverse perineal, 82(6):883-91, 1993
bulbospongiosus, and ischiocavernosus muscles
Muscles
• Superficial transverse perineal muscles
◦ Location and attachment
▪ Spans posterior edge of urogenital diaphragm
▪ Inserts into perineal body and external anal
sphincter
◦ Variably present and often less well developed in
women
• Bulbospongiosus muscle
◦ Location and attachment
▪ Originates from clitoris
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Pelvic Floor
BONY PELVIS AND LIGAMENTS
Inguinal ligament
Obturator canal
Interpubic disc
Obturator membrane
Arcuate pubic ligament
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Greater sciatic foramen
Sacrospinous ligament
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Lesser sciatic foramen
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Sacrotuberous ligament
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://
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Inguinal ligament
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Greater sciatic foramen

Obturator canal
Lesser sciatic foramen
Obturator membrane
Sacrotuberous ligament
(Top) Graphic of the pubic symphysis shows the arcuate ligament. It blends with the interpubic disc and extends laterally, attaching to the
inferior pubic rami. This is an important landmark when assessing the urethral supporting ligaments. The interpubic disc is strengthened
anteriorly by several interlacing collagenous fibrous layers passing obliquely from bone to bone. (Middle) 3D CT reconstruction shows the
posterior view of the pelvis and is graphically enhanced to show the key ligaments. The sacrospinous ligament extends between the sacrum and
ischial spine. The sacrotuberous ligament extends from the lateral part of sacrum, coccyx, and posterior inferior iliac spine to insert on the ischial
tuberosity. (Bottom) 3D reconstruction shows a medial view of the pelvic sidewall. The obturator foramen is covered by a membrane except for
the obturator canal. The greater sciatic foramen is above the sacrospinous ligament and the lesser sciatic foramen is below it.
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POSTERIOR PELVIC WALL
Psoas minor muscle Transversus abdominis

muscle with cut edge
Quadratus lumborum
muscle Internal oblique muscle (cut
Psoas major muscle edge)
External oblique muscle
(cut edge)
Iliac crest
Iliacus muscle
Anterior superior iliac spine

Piriformis muscle
Coccygeus muscle
Rectum Arcus tendineus levator ani
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Urethra
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Levator ani muscle
Iliopsoas muscle
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Lesser trochanter
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bg
ko
Gluteus medius muscle

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Left sacroiliac joint

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Piriformis muscle
Gluteus maximus muscle
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tp
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Iliococcygeus muscle
(Top) The anterior pelvic wall is the shallowest wall formed by the posterior surfaces of the bodies of the pubic bone, symphysis pubis, and pubic
rami. The posterior wall of the false pelvis is formed by the iliac bones, sacrum, and the iliacus and psoas muscles. These 2 muscles fuse caudally
to form the iliopsoas muscle, which passes anterior to the hip joint to insert onto the lesser trochanter of the femur. The posterior wall of the
true pelvis if formed by the sacrum, coccyx, and the piriformis and coccygeus muscles. The inguinal ligament is formed by the external oblique
aponeurosis and is continuous with the fascia lata of the thigh. (Bottom) Coronal T2WI MR shows the piriformis muscle originating from the
anterior sacrum. The piriformis muscle (along with the sacrum, coccyx, and covering fascia) forms the posterior pelvic wall. It then leaves the
pelvis through the greater sciatic foramen and inserts onto the upper border of the greater trochanter of the femur.
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Pelvic Floor
LATERAL PELVIC WALL
Iliac bone
Obturator internus muscle
Piriformis muscle
Obturator canal
Arcus tendineus levator ani
Ischial spine
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Coccygeus muscle
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Pubococcygeus muscle Rectum
Urogenital diaphragm
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Urethra
External anal sphincter
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Vagina
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Psoas muscle
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Piriformis muscle
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Sciatic nerve
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Obturator canal
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Obturator externus muscle

Adductor brevis muscle
Adductor longus muscle
(Top) The true pelvis is bowl-shaped; therefore, the designation of walls is somewhat arbitrary. The lateral wall of the true pelvis is formed by
part of the ilium and ischium below the pelvic inlet, the obturator internus muscle and its covering membrane, and the sacrotuberous and
sacrospinous ligaments. The pelvic floor is formed by the pelvic diaphragm (coccygeus and levator ani muscles and fascia). The levator ani is
composed of 3 separate muscles: Pubococcygeus, iliococcygeus, and puborectalis. The levator ani is attached to the pubic bones anteriorly,
the ischial spines laterally, and to the arcus tendineus levator ani (thickening in the obturator fascia) between the bony attachments. The pelvic
diaphragm separates the pelvic cavity from the perineum. (Bottom) Sagittal T1WI MR of the lateral pelvic sidewall shows the piriformis and
obturator internus muscles.
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1ST LAYER OF PELVIC FLOOR: ENDOPELVIC FASCIA (LIGAMENTS)
Urinary bladder
Cervix
Arcus tendineus levator ani

(ATLA)
Arcus tendineus fascia pelvis

Cardinal ligament (ATFP)
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Rectum
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ko
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ATFP
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ATLA
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(Top) Graphic looking down into the pelvis shows the fascia with the bladder, cervix, and rectum cut away. Endopelvic fascia is a continuous
adventitial layer, covering the pelvic diaphragm and viscera. It is a complex network of connective tissue composed of collagen, fibroblasts,
elastin, smooth muscle cells, and neurovascular bundles. Ligaments are a more well-defined aggregate of connective tissue. (Bottom) Graphic
looking down on the pelvic floor with the bladder in situ shows the arcus tendineus levator ani (ATLA) and the arcus tendineus fascia pelvis
(ATFP). The ATLA extends from the pubic ramus anteriorly and attaches posteriorly to the ischial spine. It is a condensation of the obturator
fascia and provides an important function in pelvic floor support as most of the muscles arise from it. The ATFP has a more inferior and medial
course than the ATLA, attaching to the pubis close to the pubic symphysis. It provides a lateral anchoring site for the anterior vaginal wall and
supports the urethra.
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Pelvic Floor
1ST LAYER OF PELVIC FLOOR: ENDOPELVIC FASCIA (LIGAMENTS)
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e.
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Level I: Suspension
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Vagina (uterus removed)
Level II: Attachment
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ATLA
Level III: Fusion
ATFP
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Symphysis pubis
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Right ATFP Left ATFP

tp
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(Top) There are 3 levels of endopelvic fascia support. Level I is the upper 2-3 cm of the vagina adjacent to the cervix. This gives support to the
upper vagina and uterus. Level II is the midportion of the vagina. This is the level of support for the urinary bladder. Level III is the distal 2-3 cm,
which extends to the introitus. At this level, there is no intervening paracolpium and the anterior vaginal wall is fused with the lower posterior
urethra. Level III provides urethral and vesical neck support. (Middle) This schematic diagram (uterus removed) shows the type of support the
vagina receives at each level. In level I (suspension), the paracolpium suspends the vagina from the lateral pelvic walls. Fibers of level I extend
both vertically and posteriorly toward the sacrum. In level II (attachment), the vagina is attached to the arcus tendineus fasciae pelvis and the
superior fascia of levator ani. In level III (fusion), the vagina, near the introitus, is fused laterally to the levator ani. (Bottom) Axial oblique T2WI
TSE MR shows the ATFP on either sides of the symphysis pubis.
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2ND LAYER OF PELVIC FLOOR: PELVIC DIAPHRAGM (COCCYGEUS)
Symphysis pubis
Pubic tubercle
Ischial rami
Femoral head
Ischium
Ischial spine
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Sacroiliac joint
Iliac bone
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Sacrum
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bg
ko
oo

eb
://
Left coccygeus muscle

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Right coccygeus muscle Ischial spine

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(Top) 3D CT reconstruction shows the pelvic outlet graphically enhanced to show the sacrospinous ligament. The pelvic outlet is formed by the
ischiopubic rami, ischial spines, inferior symphysis pubis, sacrospinous ligaments, and coccyx. (Bottom) Axial oblique T2WI MR at the same
level shows the coccygeus muscle. It arises from the tip of the ischial spine, and the fibers fan out and insert into the lateral side of the coccyx.
The sacrospinous ligament is at the posterior edge of the coccygeus muscle. The coccygeus muscle, along with the levator ani muscles, forms
the pelvic diaphragm. The primary function of the coccygeus muscle is to give support to the pelvic wall, but it does not have a direct role in
function, as does the levator ani.
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Pelvic Floor
2ND LAYER OF PELVIC FLOOR: PELVIC DIAPHRAGM (LEVATOR ANI)
Fascia of urogenital
diaphragm
Puborectalis muscle
Urethra
Vagina
Pubococcygeus muscle
Rectum
ATLA and fascia
Coccygeus muscle
Anterior sacrococcygeal
ligament
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Piriformis muscle
Sacrum
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ko
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Ischial spine
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Coccygeus muscle
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Rectum
Coccyx
(Top) Graphic provides superior view of the pelvic floor. The levator ani is formed by the puborectalis, pubococcygeus, and iliococcygeus
muscles. The obturator internus is covered by a fascial layer, which forms a thick band, the ATLA. This is a crucial area of attachment for
the levator ani. The levator ani muscle with the coccygeal muscles form the pelvic diaphragm (floor). The piriformis muscle contributes to
the posterior wall. (Bottom) Axial oblique T2WI MR shows the pelvic floor and parts of the levator ani. The pubococcygeus muscle passes
posteriorly. It has a bony attachment that is different from the puborectalis, which forms a sling around the anorectal junction with no bony
attachment.
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3RD LAYER OF PELVIC FLOOR: UROGENITAL DIAPHRAGM
Round ligament of uterus
Obturator vessels and nerve

Vagina
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Iliococcygeus muscle Superior fascial layer of
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urogenital diaphragm
Urogenital diaphragm Deep transverse perineal

muscle
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Inferior fascial layer of
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urogenital diaphragm
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ko
Arcuate ligament
Deep dorsal vein of clitoris
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Urethra
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Vagina
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Superficial transverse
perineal muscle
Perineal body
(Top) Coronal graphic of the pelvic floor shows the urogenital diaphragm. It is the fibromuscular layer directly below the pelvic diaphragm
(levator ani muscles). It is a trilaminar structure with the deep transverse perineal muscle sandwiched between superior and inferior fascial layers.
It is part of the perineum, which is located below the levator ani and includes the external genitalia. (Bottom) Graphic shows the inferior view of
the urogenital diaphragm. It is triangular in shape and attaches laterally to the pubic bones. At the most anterior (ventral) aspect of the perineal
membrane (covering fascia), the base of the arcuate ligament is separated from the anterior border of the urogenital diaphragm by an opening
for the deep dorsal vein of the clitoris. Both the urethra and vagina pass through the urogenital diaphragm.
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Pelvic Floor
3RD LAYER OF PELVIC FLOOR: UROGENITAL DIAPHRAGM
Rectum Cervix
Ischiorectal fossa
Urogenital diaphragm Urogenital diaphragm
t
ne
e.
Urogenital triangle
yn
bg
Superficial transverse perineal muscle
ko
Anal triangle
oo
eb
://
tp
Urogenital triangle
ht
Anal triangle
(Top) Coronal T2WI MR at the level of the urogenital (UG) diaphragm shows its location below the pelvic diaphragm. The UG diaphragm is part
of the perineum. (Middle) The perineum is bordered by the symphysis pubis, ischial tuberosities, and coccyx, creating a diamond shape. It can
be subdivided into 2 triangular compartments by a line drawn slightly anterior to the ischial tuberosities along the superficial transverse perineal
muscle, creating the urogenital triangle anteriorly and the anal triangle posteriorly. (Bottom) Axial oblique T2WI MR shows the diamond-shaped
perineum. The urogenital triangle contains the urethra, vagina, perineal membrane, and external genital muscles. The anal triangle contains the
anus and ischiorectal fossa.
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4TH LAYER OF PELVIC FLOOR: SUPERFICIAL EXTERNAL GENITAL MUSCLES
Clitoris
Ischiocavernosus muscle
Bulb of vestibule
Bulbospongiosus muscle
Perineal membrane/fascia
Greater vestibular Deep transverse perineal

(Bartholin gland) muscle
t
perineal muscle
ne
Perineal body
Anococcygeal ligament Gluteus maximus muscle
e.
yn
bg
ko
oo
eb
Right bulbospongiosus Left ischiocavernosus

muscle muscle
Bulb of vestibule Urethral orifice
://
Superficial transverse Greater vestibular gland

perineal muscle
tp
ht
Perineal body
Anal canal
(Top) The external genital muscle is located anteriorly in the urogenital triangle, whereas the anal sphincter complex and perineal body are in the
anal triangle.The perineal body is a thickened, midline condensation of fibrous tissue at the midpoint of a line joining the ischial tuberosities. At
this point, several important muscles converge and are attached: The external anal sphincter, paired bulbospongiosus muscles, paired superficial
transverse perineal muscles, and fibers of the levator ani. (Bottom) Axial oblique T2WI MR in a woman at the level of the superficial external
genital muscle shows the extension of the bulbospongiosus muscle.
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Pelvic Floor
COMPARATIVE MALE ANATOMY
Deep (Buck) fascia of penis
Bulbospongiosus muscle
Ischiocavernosus muscle Deep transverse perineal

muscle
Bulbourethral (Cowper)
Perineal membrane/fascia gland
perineal muscle
Levator ani muscle
t
ne
Anococcygeal ligament
e.
Tip of coccyx
yn
bg
ko
oo
Bulbospongiosus
eb
Ischiocavernosus
perineal muscle
://
Internal anal sphincter

Deep external anal
sphincter (EAS)
tp
ht
Tip of coccyx
(Top) Graphic shows the difference between the male and female perineum. In males, the perineal membrane is pierced by the urethra and
branches of the pudendal neurovascular bundle. The deep transverse perineal muscle and membrane form the urogenital diaphragm and
provide an attachment for the external genitalia. No such membrane exists posterior to the transverse perineal muscles (anal triangle). The
perineal body is located between urethra and anus in males. (Bottom) Axial T2WI MR at the level of the urogenital diaphragm and the external
genital muscles shows that the bulbospongiosus and ischiocavernosus are far more developed than in the female.
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PASSIVE AND ACTIVE COMPONENTS OF PELVIC SUPPORT
Cervical ring
Uterosacral ligaments
(USLs)
Suburethral ligament
Posterior anal plate
(anococcygeal ligament)
t
Perineal membrane
ne
Rectovaginal fascia
Pubocervical fascia
Pubourethral ligament
e.
Perineal body
yn
bg
ko
oo
eb
://
(PCM)
tp
Levator plate
ht
Longitudinal muscle of anus
Puborectalis muscle (PRM)

Perineal body
(Top) This series of 2 graphics illustrates the passive and active conceptual approach to the pelvic floor. Passive components include the bony
pelvis and supportive connective tissue. The supportive connective tissue is either in the form of a diffuse ill-defined layer (the endopelvic fascia),
or as well-defined specialized aggregations of connective tissue (ligaments). The 3 endopelvic fascial levels include level I (upper vagina adjacent
to the cervix), level II (midportion of the vagina), and level III (from the introitus to 2–3 cm above the hymenal ring). (Bottom) Graphic shows
the main active component of pelvic support system, the levator ani muscle. The levator ani muscle is a wide sheet of muscle that has a linear
origin from the back of the body of the pubis, the arcus tendineus levator ani and ischial spine. Its main components are the puborectalis muscle,
which forms a sling around the junction of the rectum and anal canal, the pubococcygeus muscle, which passes posteriorly to insert into the
anococcygeal body, and the iliococcygeus muscle, whose fibers fuse to form the levator plate and insert on coccyx.
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Pelvic Floor
PASSIVE AND ACTIVE COMPONENTS OF PELVIC SUPPORT
t
ne
Uterosacral ligaments
e.
ATFP
yn
bg
Pubocervical fascia
ko
Perineal membrane Levator plate
oo
Rectovaginal fascia
eb
Puborectalis muscle
Longitudinal muscle of
://
anus
tp
Urethra External anal sphincter

ht
Perineal body
Graphic of the pelvis illustrates the multilayered system approach that considers the passive and active components of pelvic floor as an
integrated multilayer system. From cranial to caudal, the pelvic support system consists of endopelvic fascia, pelvic diaphragm, perineum, and
the external genital muscles. The muscles (levator ani) give active support to the pelvic floor whereas the ligaments give passive support holding
organs in place. When the levator ani is functioning properly, the pelvic floor is closed and the ligaments and fasciae are under no tension. When
the musculature is damaged and cannot close the levator hiatus, ligaments are put under strain and will eventually fail resulting in pelvic organ
prolapse.
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FUNCTIONAL 3-PART PELVIC SUPPORT SYSTEM
Space of Retzius
Urethra
Puborectalis muscle
Vagina
Periurethral ligament
t
ne
e.
Normal posterior bladder
yn
bg
Uterine cervix
ko
Rectum
oo
Sacrum
eb
://
tp
ht

Deep EAS
Intersphincteric space
(Top) Key elements of the functional 3-part pelvic support system are shown. This approach includes the urethral support including supporting
ligaments, level III endopelvic fascia, and the puborectalis muscle. The urethra is midline, the vagina is normal in shape, and the space of Retzius
is small and symmetric in appearance. (Middle) Axial T2WI MR shows the normal vaginal support system. Level I and II endopelvic fascial
attachment are evaluated at the level of the uterine cervix and bladder base, respectively. When normal, the posterior urinary bladder wall is
more or less straight, as seen here. (Bottom) Axial balanced fast field echo (BFFE) MR shows the anal sphincter complex, which along with pelvic
floor muscles, is responsible for anal continence. The deep external anal sphincter (EAS) has a characteristic teardrop appearance.
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Pelvic Floor
AXIAL OBLIQUE MR OF LEVATOR ANI
Vagina

Rectum
Puborectalis muscle
t
ne
e.
yn
Vagina
Rectum
Puborectalis & pubococcygeus muscles
bg
ko
oo
eb
://
Urethra
Vagina
tp

Rectum
ht
Tip of coccyx
(Top) Three consecutive T2WI MR show the relationship of the puborectalis and pubococcygeus muscles, 2 components of the levator ani
muscle. The puborectalis muscle can be differentiated from the pubococcygeus muscle on axial plane as it forms a sling around the rectum and
does not insert into any skeletal structure. (Middle) Axial oblique T2WI MR at a slightly higher level shows the transition from the puborectalis
muscle to the pubococcygeus, as the muscle fibers start to have a bony attachment. No distinct plane of separation will be seen. (Bottom) Axial
oblique T2WI MR at a slightly higher level shows the pubococcygeus muscle fibers inserting into the lateral parts of coccyx. Axial oblique is the
only plane that demonstrates this attachment.
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MR OF PUBORECTALIS MUSCLE
Puborectalis muscle fiber bundles

Pubic bone
Pubococcygeus muscle fiber bundles
t
ne
Symphysis pubis
e.
yn
Urethra
Puborectalis and pubococcygeus

muscle
bg
Vagina
ko
oo
eb
://
tp
Urethra
Vagina
Puborectalis muscle
ht
Rectum
(Top) Sagittal T2WI MR shows how to differentiate between the pubococcygeus and puborectalis muscle. The pubococcygeus muscle is inferior
and has an obliquely oriented course. The puborectalis muscle is superior and is situated in a nearly horizontal plane. (Middle) Axial T2WI MR
in the same woman at the level of the symphysis pubis shows fusion of the puborectalis and pubococcygeus muscles to the distal vagina, making
it difficult to differentiate these muscles at this level. (Bottom) Axial T2WI MR in the same woman at a higher level shows a space between the
puborectalis muscle and the vagina. This is the level where only the puborectalis is present.
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Pelvic Floor
MR OF ILIOCOCCYGEUS MUSCLE
Origin of puborectalis from pubic bone Origin of iliococcygeus muscle
Anal canal
t
ne
e.
Urethrovesical junction
Origin of iliococcygeus muscle
yn
Obturator internus Iliococcygeus muscle
bg
ko
oo
eb
://
Bladder base
tp
Vagina Obturator internus

ht
(Top) Axial T2WI MR shows transition from the puborectalis muscle to the iliococcygeus muscle. The right side shows part of the puborectalis
and the iliococcygeus muscles due to minimal obliquity of the patient. On the left, the origin of the iliococcygeus muscle is clearly seen from the
fascia covering the obturator internus muscle. (Middle) Axial T2WI MR in the same woman shows the origin of the iliococcygeus muscle from
the obturator internus. (Bottom) Axial T2WI MR shows the iliococcygeus muscle just slightly higher. The puborectalis muscle is thicker than the
iliococcygeus, a finding that can help differentiate them in the axial plane.
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Uterine cervix
Obturator internus
Iliococcygeus muscle sling
t
ne
e.
yn
bg
Iliococcygeus muscle sling on left side
Rectum bulging anteriorly during

ko
maximum straining
oo
eb
://
tp
ht
Left iliococcygeus muscle sling

Right iliococcygeus muscle sling
(Top) Coronal T2WI gradient fast spin-echo MR shows the iliococcygeus muscle at rest. This is an anterior section at the level of the hip joint. The
iliococcygeus muscle is sloped, and the origin of the muscle from the obturator internus muscle can be visualized. It is worth mentioning that
the MR sequences acquired in the dynamic part of the study at rest and during maximum straining are usually of lower resolution to minimize
acquisition time. (Middle) Coronal T2WI gradient fast spin-echo MR in the same woman is shown during maximum straining. The iliococcygeus
is elongated and assumes a more vertical orientation compared to the resting phase. (Bottom) Coronal T2WI gradient fast spin-echo MR in a
different woman at maximum straining is shown for comparison. The iliococcygeus muscle shows abnormal elongation of its muscle sling on
both sides, suggestive of mild to moderate pelvic floor muscle weakness.
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Pelvic Floor
Rectum
Anal canal
t
ne
Sacrum
Sacroiliac joint
e.
yn
Rectum
bg Iliococcygeus muscle
Anal sphincter complex

ko
oo
eb
Sacrum
Sacroiliac joint
://
tp
Rectum
ht
(Top) Coronal T2WI gradient fast spin-echo MR shows the iliococcygeus muscle at the level of the anal canal. A fibrofatty tissue separates the
muscle bundles at their origin. This fibrofatty tissue appears as gaps on coronal sections and should not be mistaken for a defect. (Middle)
Coronal T2WI gradient fast spin-echo MR shows the iliococcygeus muscle at the level of the sacroiliac joint. From anterior to posterior, the
muscle slope decreases. (Bottom) Coronal T2WI gradient fast spin-echo MR at the same level is shown during straining. More posteriorly, the
slope of the muscle and the degree of elongation are less compared to those of the section at the level of the anal canal.
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MR OF PELVIC FLOOR MUSCLES
Uterus
Rectum
Urinary bladder
Puborectalis
Pubic bone
EAS
t
ne
e.
yn
Urinary bladder
Levator plate
bg
Symphysis pubis Puborectalis
ko
Anal canal
oo
eb
://
tp
ht
Urinary bladder
Puborectalis
Tip of coccyx
Pubic bone
Fibers of anococcygeal ligament
Deep EAS
(Top) Sagittal BFFE MR shows a woman with normal pelvic floor musculature. In the sagittal plane, the puborectalis is seen immediately superior
to the deep external anal sphincter. (Middle) On a paramedian section, the puborectalis muscle and the levator plate are the main muscles
visualized. (Bottom) Sagittal BFFE MR in the same woman shows how to differentiate between the puborectalis and the external anal sphincter.
The deep portion of the sphincter ani externus is indirectly fastened to the coccyx by the fibers of the anococcygeal ligament.
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Pelvic Floor
AXIAL MR OF PELVIC FLOOR MUSCLES
Vagina
Vesicourethral junction
Transition between PR and
IC muscle IC muscles
PR muscle attachment to
pubic bone Arcus tendineus fascia pelvis
t
ne
Level of PR and PC muscles
e.
yn
bg
ko
oo
Distal 1/3 of urethra
PC muscle
eb
Vagina
://

tp
Bulbospongiosus muscles
ht
Overlap between EAS and

PC muscle
(Top) Consecutive axial T2WI MR of a female volunteer are shown. The sections are plotted perpendicular to the longitudinal axis of the pelvis.
The images show subdivisions of the pelvic floor muscle (IC = iliococcygeus muscle; PR = puborectalis muscle, PC = pubococcygeus muscle,
EAS = external anal sphincter). (Bottom) Consecutive axial T2WI MR of the same female volunteer at a more caudal level show subdivisions of
the pubococcygeus muscle and external anal sphincter. At the level of the perineum, the external genital muscles are seen anterior to the anal
canal. At the level of the inferior pubic rami, the pubococcygeus muscles are seen.
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CORONAL MR OF PELVIC FLOOR MUSCLES
Urinary bladder Urinary bladder in more

posterior section
Pubic symphysis Urethra
Perineal muscles and

membrane traversed by
urethra
t
ne
IC muscle
IC muscle
e.
yn
perineal muscle
bg
Sacroiliac joint
ko
IC muscle
oo
Origin of IC muscle from

obturator internus muscle
Overlap of PR muscle and
eb
Obturator internus muscle EAS

://
tp
Overlap between IC and

Piriformis muscle coccygeus muscle
ht
PR muscle
Most posterior aspect of EAS
EAS
Superficial EAS
(Top) Serial coronal images obtained in a female volunteer are displayed from anterior to posterior. These 4 images show the anatomy of the
perianal structures and the anterior part of the iliococcygeus muscle. The urethra is seen passing through the urogenital diaphragm and layers of
the perineum. (Bottom) Serial coronal images obtained in the same woman at a more posterior level show the anatomy of the posterior part of
the iliococcygeus muscle and anal sphincter complex.
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Pelvic Floor
SAGITTAL MR OF PELVIC FLOOR MUSCLES
Most lateral extension of

iliococcygeus muscle
Obturator internus muscle Iliococcygeus muscle

Pubic bone
Iliococcygeus muscle Uterus
Vaginal fornix
t
ne
Pubic bone Iliococcygeus muscle
e.
yn
bg
ko
Vaginal fornix
oo
EAS lateral to midline

Posterior vaginal wall
eb
://
Levator plate
tp
ht
PR muscle
PR muscle
EAS
EAS
Perineal body
(Top) Serial sagittal images obtained in a female volunteer displayed from lateral to medial show the lateral part of the iliococcygeus muscle
and the more curved slope of the muscle away from the midline at its origin from the obturator internus muscle. (Bottom) Serial sagittal images
obtained in a female volunteer at a more medial level display the normal MR anatomy of anal sphincter and of the levator plate.
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Pelvic Floor PELVIC FLOOR IMAGING
▪ Injection of ultrasound gel as vaginal contrast is

INDICATIONS mainly indicated in cases of vaginal vault prolapse
Preoperative and Treatment Planning Patient Position
• Preoperative diagnosis in patients with symptoms of • Supine on MR table with multicoil array wrapped low
multicompartmental pelvic floor dysfunction (PFD) around pelvis
with planned complex repair
• Determine which pelvic compartments are damaged Sequences
and identify specific muscle defects • Static
• Determination of appropriate surgical approach ◦ High spatial resolution
◦ Anterior vaginal wall prolapse (cystocele) ◦ Used to delineate3 parts of pelvic supporting systems
▪ Cystocele alone is treated with a retropubic (Burch) • Fast imaging dynamic (cine)
colposuspension, which entails suspending lateral ◦ Indicated for evaluation of functional abnormalities
aspects of bladder from pelvic sidewall ◦ Localizing images are obtained to identify midline
▪ When fascia is detached from tendinous arch, sagittal plane that shows pubic symphysis, urethra,
paravaginal fascial repair is added vagina, rectum, and coccyx
◦ Uterine prolapse ◦ Dynamic sequences are performed with gradient-
▪ Usually treated with hysterectomy and uterosacral echo or single shot fast spin-echo sequences, e.g.,
suspension, sometimes with addition of mesh balanced fast field echo (BFFE)
◦ Dynamic MR imaging is performed in sagittal, axial,
t
support
ne
◦ Enterocele and coronal planes
▪ Rectovaginal fascia is reapproximated
◦ Rectocele
Phases of Dynamic MR Protocols
• In each plane, 5 sections are acquired during 6 phases
▪ Repair entails posterior colporrhaphy
e.
◦ Each takes ~ 10 seconds
Postoperative Evaluation • Images are acquired during the following phases
◦ At rest
yn
• Detection of postoperative complications
• Evaluation of persistent complaints ◦ Withholding (contraction of pelvic floor)
• Evaluation of recurrent symptoms ◦ Mild straining
◦ Occur in 10-30% of patients who undergo repair ◦ Moderate straining
bg
▪ Usually due to defects that were not diagnosed ◦ Maximum straining
preoperatively ▪ Repeat maximum straining to ensure maximal
• Evaluation of new symptoms that were not present Valsalva maneuver
ko
preoperatively
Precautions to Ensure Proper Dynamic MR
BEFORE MR Techniques
oo
• All patients should be given instructions before MR

Clinical Evaluation ◦ Key element of MR in PFD is to image patient during
• Symptoms of PFD range from vague lower back pain to different maneuvers in > 1 plane
eb
major fecal &/or urinary incontinence ◦ Patients require coaching on contraction of pelvic
• At initial evaluation, patient may be unaware that floor (withholding)
many symptoms experienced may be related to PFD ▪ Instructed to squeeze buttocks as if trying to
• Comprehensive history encompassing all pertinent
://
prevent escape of urine

areas should be performed ◦ Patients require coaching on grades of straining to
• Symptoms are divided arbitrarily into different areas, achieve maximal pelvic strain
tp
although coexisting symptoms of all types often exist in ▪ Instructed to bear down as much as possible as if
same individual constipated and trying to defecate
◦ Urinary disorders, fecal disorders, sexual dysfunction,
ht
• Recommended that radiologist attends MR to minimize

pelvic discomfort variations between examinations by
◦ Ensuring compliance to different instructions
IMAGING TECHNIQUE ◦ Monitoring and ensuring that image acquisition
occurs during maximum straining effort
Patient Preparation ▪ Observe movement of anterior abdominal wall
• All patients should undergo cleansing rectal enema ▪ Follow movement of pelvic organs
(using warm water) night before examination
• MR protocol requires no oral or intravenous ANALYSIS OF DYNAMIC
administration of contrast agents
• For imaging of urinary bladder, patients are asked to IMAGES IN SAGITTAL PLANE
void 2 hours before examination General Principles
◦ Comfortably full bladder is important because
• Measurements are made in 2 main phases
overdistension may prevent uterine and small bowel ◦ Maximum straining phase (measurements are
descent
•
made in sagittal, axial, and coronal planes)
Opacification of pelvic organs ◦ MR defecography (evacuation phase)
◦ Different protocols adopted
• Pelvic floor muscle contraction phase (withholding)
▪ 90-120 mL of ultrasound gel placed into rectum
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PELVIC FLOOR IMAGING
Pelvic Floor
◦ Can be considered as reference to ability of patient to Supportive Measurements
contract pelvic floor muscle • Parameters in sagittal plane
Pelvic Organ Prolapse (POP) ◦ H-line
• ▪ Measured on midsagittal image during maximum
Best evaluated on midsagittal MR images during rest
and at maximum straining, when pelvic organ descent straining phase
▪ Midline structures are landmarks for plotting H-
is greatest
• Position of various pelvic organs is compared to line
▪ Measured from inferior aspect of pubic symphysis
horizontal reference line
◦ Pubococcygeal line (PCL) is most commonly used to anorectal junction
▪ Anorectal junction is determined by posterior
reference
▪ Drawn from inferior border of the symphysis pubis indention by puborectalis muscle
▪ Length of H-line: 5.8 cm
to last coccygeal joint
• ◦ M-line
Measurement of pelvic organ descent
◦ Positions of bladder neck, vaginal vault, and ▪ Measured on midsagittal image during maximum
anorectal junction are measured at 90° angle to PCL straining phase

◦ Organ-specific reference points are used in each ▪ Drawn as perpendicular line from PCL to posterior
compartment aspect of H-line

• ▪ Length of M-line: 1.3 cm ± 0.5 SD
Anterior compartment
◦ Levator plate angle (LPA)
t
◦ Bladder neck descent (BND)
ne
▪ Organ-specific reference point is urethrovesical ▪ Measured on midsagittal image
▪ Levator plate angle is drawn between axis of levator
junction (UVJ)
▪ BND is defined as abnormal if > 1 cm below PCL plate and PCL
▪ Levator plate angle: 11.7° ± 4.8 SD
e.
◦ Bladder base descent
▪ Organ-specific reference point is most posterior • Parameter measured in axial plane
◦ Width of levator hiatus (WLH)
and inferior aspect of bladder base
yn
▪ Cystocele: Defined as descent of bladder base > 1 ▪ Measured on axial image at most inferior point of
cm below PCL symphysis pubis during maximum straining

• ▪ Distance enclosed between puborectalis muscle
Middle compartment
bg
◦ Retrocervical descent slings
▪ Organ-specific reference point is anterior cervical ▪ WLH rarely exceeds 4.5 cm ± 0.7 SD in women
lip with intact pelvic floor

ko
▪ Normally no descent of cervix below PCL • Parameter measured in coronal plane

◦ Post hysterectomy (vaginal vault prolapse) ◦ Iliococcygeus angle (ILCA)
▪ Organ-specific reference point is posterosuperior ▪ Measured on coronal posterior image at level of
oo
vaginal apex anal canal during maximum straining

▪ Defined as descent of vaginal apex below PCL ▪ Angle defined by line plotted along iliococcygeus
◦ Enterocele, sigmoidocele muscle sling and transverse plane of pelvis
▪ Defined as small bowel or sigmoid colon below PCL ▪ Mean of ILCA is reported to be 33.4° ± 8.2 SD in
eb
◦ Peritoneocele women with intact pelvic floor

▪ Defined as herniation of peritoneal cul-de-sac ±
small bowel MR DEFECOGRAPHY
://
• Posterior compartment
◦ Anorectal junction descent (ARJD)
Definitions
•
tp
▪ Organ-specific reference point is anterior aspect of

Acquiring MR images while patient is evacuating
intrarectal ultrasound gel
anorectal junction •
▪ Anorectal junction is defined by posterior
With addition of MR defecography, technique of MR
ht
imaging parallels that of fluoroscopic conventional

impression of puborectalis muscle at most cranial
defecography
extent of anal canal
▪ Descent is defined as excessive if > 2-2.5 cm Indication
◦ Rectocele • Evacuation phase is mandatory for dynamic MR
▪ Defined as any rectal bulge anterior to line examination of pelvic floor
extended upward along anterior anal canal ◦ Unmasks pelvic organ prolapse that may not be
• Grading of POP severity according to "rule of 3" apparent during maximum straining
◦ Mild: < 3 cm descent of organ below PCL • Anorectal dysfunction
◦ Moderate descent by 3-6 cm ◦ Considered crucial for diagnosis of PFD related to
◦ Severe descent by > 6 cm posterior compartment
◦ Specifically in patients complaining about obstructed
Stress Urinary Incontinence (SUI)
•
defecation
Diagnosed during maximum straining ▪ In this group of patients, evacuation phase is of
• Recorded when loss of urine through urethra is
critical significance in diagnosis
visualized ▪ If patient failed to evacuate during MR
◦ However, absence of urine loss during MR
study, conventional defecography should be
examination does not preclude patient experiencing
symptoms
recommended
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Patient Preparation RELATED REFERENCES

• All patients undergo cleansing rectal enema (using
1. El Sayed RF: Female pelvic floor dysfunction. In Morcos SK
warm water) night before MR et al: Urogenital Imaging: A Problem-Oriented Approach.
• MR protocol requires no oral or intravenous Chichester: Wiley-Blackwell. 399–413, 2009
administration of contrast agents 2. El Sayed RF et al: Pelvic floor dysfunction: assessment with
• 90-120 mL of ultrasound gel placed into rectum combined analysis of static and dynamic MR imaging
• Pelvic organs findings. Radiology. 248(2):518-30, 2008
◦ Imaging of urinary bladder and pelvic organs follow 3. Lienemann A et al: Assessment of pelvic organ descent by
routine dynamic MR protocol use of functional cine-MRI: which reference line should be
• Patient training used? Neurourol Urodyn. 23(1):33-7, 2004
◦ Patient is informed that evacuation phase is crucial 4. Kelvin FM et al: Dynamic cystoproctography: Fluoroscopic
and MR techniques for evaluating pelvic organ prolapse. In
for complete diagnostic study Bartram CI et al: Imaging Pelvic Floor Disorders. New York:
◦ Radiologist should explain that this phase is
Springer. 51-68, 2003
important because POP is often only evident when 5. Lienemann A et al: Functional imaging of the pelvic floor.
abdominal pressure increases Eur J Radiol. 47(2):117-22, 2003
▪ Best achieved during evacuation of rectum 6. Fielding JR: Practical MR imaging of female pelvic floor
weakness. Radiographics. 22(2):295-304, 2002
Imaging Technique 7. Singh K et al: Magnetic resonance imaging of normal levator
• Patient position ani anatomy and function. Obstet Gynecol. 99(3):433-8,
t
◦ Patient lies supine on MR table 2002
ne
◦ For comfort, patient may want to bend knees to 8. Hoyte L et al: Two- and 3-dimensional MRI comparison of
levator ani structure, volume, and integrity in women with
facilitate evacuation of gel
stress incontinence and prolapse. Am J Obstet Gynecol.
◦ Pad is placed under patient to avoid contamination of
e.
185(1):11-9, 2001
MR table 9. Kelvin FM et al: Female pelvic organ prolapse: a comparison
▪ Adds more comfort to patient when evacuating of triphasic dynamic MR imaging and triphasic fluoroscopic
yn
rectum cystocolpoproctography. AJR Am J Roentgenol. 174(1):81-8,
• In sagittal plane 2000
◦ Patient is asked to evacuate injected intrarectal gel, 10. Lienemann A et al: [Functional MRI of the pelvic floor. The
methods and reference values.] Radiologe. 40(5):458-64,
and image acquisition occurs continuously as 1 phase
bg
◦ With addition of evacuation phase to routine MR 2000
11. Pannu HK et al: Dynamic MR imaging of pelvic organ
protocol, 1 maximum straining phase could be prolapse: spectrum of abnormalities. Radiographics.
acquired without repetition
ko
20(6):1567-82, 2000
• In coronal plane 12. Comiter CV et al: Grading pelvic prolapse and pelvic floor
◦ Recommended to add evacuation sequence relaxation using dynamic magnetic resonance imaging.
in coronal plane in addition to routine MR Urology. 54(3):454-7, 1999
oo
defecography in sagittal plane 13. Kelvin FM et al: Female pelvic organ prolapse: diagnostic
▪ Imaging patient during conventional defecography contribution of dynamic cystoproctography and
comparison with physical examination. AJR Am J
in anteroposterior (AP) position (coronal plane)
eb
Roentgenol. 173(1):31-7, 1999

enhances detection of intussusception in some 14. Healy JC et al: Magnetic resonance imaging of the pelvic
patients floor in patients with obstructed defaecation. Br J Surg.
◦ Obtaining coronal oblique images parallel to anal 84(11):1555-8, 1997
://
canal is better 15. Kelvin FM et al: Dynamic cystoproctography of female

▪ Improved visualization of anal canal lumen pelvic floor defects and their interrelationships. AJR Am J
▪ Display evacuation process in more complete detail Roentgenol. 169(3):769-74, 1997
tp
16. Lienemann A et al: Dynamic MR colpocystorectography

Precautions to Ensure Proper Dynamic MR assessing pelvic-floor descent. Eur Radiol. 7(8):1309-17,
Techniques 1997
ht
17. Kelvin FM et al: Evacuation proctography (defecography):

• Tailoring MR defecography imaging techniques in an aid to the investigation of pelvic floor disorders. Obstet
certain PFDs Gynecol. 83(2):307-14, 1994
◦ Helpful in patients with obstructed defecation to 18. Ozasa H et al: Study of uterine prolapse by magnetic
increase amount of intrarectal gel to 160-200 mL resonance imaging: topographical changes involving the
▪ Frequently, patients cannot evacuate the rectum levator ani muscle and the vagina. Gynecol Obstet Invest.
during MR examination while lying supine when 34(1):43-8, 1992
given usual volume of gel 19. Yang A et al: Pelvic floor descent in women: dynamic
evaluation with fast MR imaging and cinematic display.
Reporting MR Defecography Radiology. 179(1):25-33, 1991
• Same criteria measured during maximum straining is
compared during evacuation to assess
◦ Significant increase of pelvic organ descent during
evacuation compared to maximum straining
◦ Development of new pelvic organ descent
◦ Unmasking of other PFDs, especially anorectal
dysfunction, that were not detected during
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Pelvic Floor
DYNAMIC MR: SAGITTAL PLANE
Uterus
Urinary bladder
5 slices plotted for sagittal dynamic

sequences
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Anterior abdominal wall muscles
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Rectum
bg Levator plate
Urinary bladder
ko
Tip of coccyx
Pubic symphysis
Anal canal
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Bulging of anterior abdominal wall

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muscles
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Levator plate
Urinary bladder
Symphysis pubis Anal canal
(Top) Coronal T2WI turbo spin-echo (TSE) MR shows plotting of the sagittal dynamic sequences. Dynamic MR imaging is performed in the
sagittal plane, which is essential. In the sagittal dynamic sequence, 5 sections are acquired during 5 phases. These are resting, withholding, mild
strain, moderate strain, and maximal strain (which is repeated). (Middle) Sagittal T2 balanced fast field echo (BFFE) MR shows a woman at the
resting (neutral) phase of the sagittal dynamic sequence. Dynamic sequences are performed with gradient-echo or single shot fast spin-echo
sequences. A midline sagittal plane that shows the pubic symphysis, urethra, vagina, rectum, and coccyx should be the middle slice of the 5
sections. (Bottom) Sagittal T2 (BFFE) MR shows the same woman during maximum straining. It is recommended to monitor the patient to ensure
their compliance with the instructions. To ensure that image acquisition occurs during the maximum straining effort, observe the movement of
the anterior abdominal wall muscles.
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DYNAMIC MR: AXIAL PLANE
Cervix
Levator plate
Urinary bladder
Perineal body
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Puborectalis muscle
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Vagina
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Rectum
ko
oo
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tp
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(Top) Sagittal T2WI turbo spin-echo (TSE) MR of a woman shows the plotting of the axial dynamic sequences. Five sections are acquired
during 6 phases. The midsection of the 5 slices should be placed opposite the inferior border of the symphysis pubis to ensure covering of
the puborectalis muscle cranially and the urogenital hiatus caudally. (Middle) Axial T2 balanced fast field echo (BFFE) MR shows a woman at
rest. This is the level (most inferior point of symphysis pubis) where the width of levator hiatus (WLH) is measured. This level is at the inferior
aspect of the symphysis pubis and pubic bones. (Bottom) Axial T2 balanced fast field echo (BFFE) MR shows the same woman during maximum
straining. The WLH is measured at maximum straining. The transverse diameter of the muscle reflects the extent of its ballooning during straining.
In healthy volunteers with no symptoms of pelvic floor dysfunction, WLH rarely exceeds 4.5 cm ± 0.7 SD.
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DYNAMIC MR: CORONAL PLANE
t
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e.
yn
bg
ko
oo
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://
tp
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(Top) Sagittal T2WI turbo spin-echo (TSE) MR of a woman shows the plotting of the coronal dynamic sequences. Five sections are acquired
during 6 phases. These sections should cover the levator plate and anorectal junction. (Middle) Axial T2 BFFE MR shows a woman at rest.
(Bottom) Axial T2 BFFE MR shows the same woman during maximum straining. The iliococcygeus angle (ILCA) is measured between lines drawn
along 1 of the iliococcygeus muscle slings and the transverse plane of the pelvis. The transverse plane of the pelvis is defined by a line drawn
between the origins of the iliococcygeus muscle slings from the obturator internus. The muscle origin is usually seen at the level of the anal canal.
The iliococcygeus muscle should move downward with no excessive caudal descent or elongation. The ILCA reflects the degree of descent and
movement of the muscle. The mean of the ILCA in a control group is 33.4° ± 8.2 SD.
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DYNAMIC MR: SAGITTAL PLANE MEASUREMENTS
Urinary bladder
Symphysis pubis
Pubococcygeal line
Anorectal descent
t
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Urinary bladder
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bg Pubococcygeal line
Symphysis pubis
ko
M-line
H-line
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Uterus
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Urinary bladder
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Symphysis pubis
(Top) Sagittal T2 balanced fast field echo (BFFE) MR shows a woman at rest. The interpretation of the sagittal MR images begins by drawing
the pubococcygeal line (PCL), which extents from the inferior border of the symphysis pubis to the last coccygeal joint. Pelvic organ descent
is measured perpendicularly to the PCL. Pelvic organ descent of > 2 cm is often indicative of the need for surgical intervention. The anorectal
junction descent (ARJD) is defined as excessive if > 2.5 cm at maximum straining. (Middle) Sagittal T2 BFFE MR of the same woman at rest
shows the measurement of the H-line, which extends from the inferior aspect of the pubic symphysis to the anorectal junction, and the M-line,
which is drawn as a perpendicular line from the PCL to the posterior aspect of the H-line. (Bottom) Sagittal T2 BFFE MR shows the same woman
during maximum straining. The levator plate angle (LPA) is defined by the PCL and the axis of the levator plate.
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MR DEFECOGRAPHY: SAGITTAL PLANE
Uterus
Urinary bladder
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yn
bg
Uterus
ko
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Anterior abdominal wall

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during evacuation
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Symphysis pubis
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Anal canal opacified with

injected gel
(Top) Coronal T2WI MR shows how to plot the sections of the MR defecography to acquire images in the sagittal plane. It is recommended
to place the sections with the middle slice passing through the anal canal lumen. 3-5 slices are recommended with thin slice thickness and
minimum interslice gap. The patient is instructed to start evacuation of the injected intrarectal gel once the loud sound of the MR starts, and the
image acquisition occurs continuously as 1 phase. (Bottom) Sagittal T2 BFFE MR shows a woman during evacuation of the injected intrarectal
gel. It is recommended to start with the sagittal evacuation sequence before the dynamic (cine) MR straining sequences to avoid loss of the
injected intrarectal gel during maximum straining.
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MR DEFECOGRAPHY: CORONAL PLANE
Urinary bladder
Pubic bone
t
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e.
yn
bg
ko
oo
eb

://
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Anal canal lumen

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(Top) Coronal T2WI MR shows how to plot the sections of the MR defecography to acquire images in the coronal oblique plane. It is
recommended to plot the sections on a midsagittal section in which the whole length of the anal canal is visualized so that the 5 slices can be
placed with the middle slice passing through the anal canal lumen. (Bottom) Coronal T2 BFFE MR of a woman during evacuation shows the
anal canal lumen delineated through its whole length with the gel during the evacuation phase. The addition of the coronal MR defecography as
part of the routine MR defecography is extremely valuable, especially in a patient with anorectal dysfunction in whom rectal intussusception is
suspected.
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Pelvic Floor
MR DEFECOGRAPHY: SAGITTAL PLANE
Uterus
Anterior abdominal wall at rest
Symphysis pubis
Anal canal closed at rest
t
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Urinary bladder
e.
yn
bg
Anterior abdominal wall during
straining
ko
Anal canal
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eb
://
tp

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Symphysis pubis
Anal canal
Anterior rectal wall bulge
(Top) Sagittal T2 balanced fast field echo (BFFE) MR of a woman with no symptoms of pelvic floor dysfunction at rest shows how the pelvic
organs' descent is measured. (Middle) Sagittal T2 BFFE MR of the same woman during maximum straining shows how to measure the LPA.
(Bottom) Sagittal T2 BFFE MR of the same woman during evacuation of the injected intrarectal gel shows passage of the injected rectal gel with
delineation of the anal canal lumen. The posterior anorectal junction is almost effaced, which is considered an important criterion of normal
defecography. The mild anterior rectal wall bulge is accepted up to 2 cm, as long as it is asymptomatic. This is a common finding in 20% of
female patients.
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Pelvic Floor OVERVIEW OF THE ANTERIOR COMPARTMENT
▪ Has poorly developed outer circular layer and well-

TERMINOLOGY developed inner longitudinal layer
Abbreviations • Outer striated muscle sphincter: Rhabdosphincter
• Pubourethral ligament (PUL) or external urethral sphincter (EUS)
◦ Proximal pubourethral ligament (PPUL) ◦ Upper sphincteric portion
◦ Intermediate pubourethral ligament (IPUL) ▪ Thickest in middle of urethra; level of maximal
◦ Distal pubourethral ligament (DPUL) closure pressure
• ▪ At superior and inferior parts of urethra, external
Suburethral ligament (SBUL)
• External urethral sphincter (EUS) urethral sphincter is deficient posteriorly
• ◦ Low arch-like pair of muscle bands occupy distal
Compressor urethrae (CU)
• Urethrovaginal sphincter (UVS) 1/3 of urethra
▪ 2 strap-like bands in distal 1/3 of urethra:
Definitions Compressor urethrae (CU), urethrovaginal
• Components of anterior compartment include urinary sphincter (UVS)
bladder, urethra, and urethral support system
Functional Correlation of Urethral Wall
• Urethral mucosa
URINARY BLADDER
◦ Rich vascular supply of lamina propria has function
Location and Description in urethral closure by coaptation of mucosal surfaces
t
• Extraperitoneal, immediately behind pubic bones (mucosal seal)
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◦ Bladder wall has 3 layers ▪ This mechanism is influenced by estrogen level
▪ Inner mucous membrane of transitional ◦ Proximal and distal submucosal vascular plexus
epithelium contribute to increased resting tone of urethra
e.
▪ Detrusor smooth muscle layer ▪ Occlusion of arterial flow into this area decreases
▪ Outer loose adventitial layer, except behind trigone resting closure pressure
• Muscular coat
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Bladder Support ◦ Inner smooth muscle sphincter
• Anteriorly: Fibromuscular pubovesical muscle ▪ Circular fibers contribute to urethral constriction
(ligament) ▪ Longitudinal fibers may contribute to normal
◦ Smooth muscle extension of detrusor muscle to arcus
bg
micturition by shortening urethra
tendineus fascia pelvis ◦ Outer striated muscle sphincter (EUS)
▪ May assist in opening bladder neck during voiding
▪ All 3 portions of EUS (upper sphincteric
ko
• Posteroinferior support to trigone: Lateral ligaments of portion), CU, UVS are part of same muscle
bladder and attachments to cervix uteri and to anterior group and function as a unit
vaginal fornix ▪ Upper sphincteric portion maintains constant tone
•
oo
Bladder base: Rests on pubocervical fascia for active urethral closure at rest
◦ Part of endopelvic fascia suspended between arcus
▪ CU and UVS with their low arch-like configuration
tendineus fascia pelvis compress urethra at its ventral aspect
• Bladder neck: Rests on upper surface of urogenital ▪ Contraction of EUS (3 parts) as a whole would
eb
diaphragm constrict lumen of urethra in its upper portion and

◦ Junction of bladder neck and urethra lies dorsal to
compress its ventral wall in lower 1/3
midportion of pubic bone • Urethra undergoes marked histologic and morphologic
://
◦ Bladder neck position is influenced by attachments

changes during aging
between puborectalis muscle, vagina, and proximal ◦ Striated muscle decreases and is replaced by
tp
urethra connective tissue

◦ When bladder fills, posterior surface and neck remain
◦ Decreased muscle bulk contributes to lower urethral
more or less unchanged in position resting tone, and with denervation, plays important
ht
role in genesis of urinary incontinence

FEMALE URETHRA
Topographic Anatomy of Female Urethra
Location and Description • Functionally, urethra is best examined by dividing it
• Complex muscular tube; ~ 4 cm in length into anatomic segments responsible for continence
• Urethral wall consists of inner mucosal membrane ◦ Bladder neck and proximal urethra
and outer muscular coat ▪ Extends from bladder outlet to where urethra
• Inner mucosal membrane consists of passes inferior margin of pubic bone
◦ Transitional epithelium proximally, changing to ▪ Considered initial segment; makes up 20% of total
nonkeratinizing stratified epithelium in mid and urethral length
distal urethra ▪ Surrounded by trigonal ring and detrusor
◦ Lamina propria: Supportive layer of loose tissue
musculature
underlying epithelium ◦ Mid urethral segment
◦ Urethral glands: Located in submucosa, concentrated ▪ Extends from inferior margin of pubic bone
in mid to lower 1/3 of urethra through urogenital diaphragm
• Outer muscular coat ▪ Upper part is sphincteric portion of EUS and
◦ Inner smooth muscle sphincter: Lissosphincter
urethral smooth muscle
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OVERVIEW OF THE ANTERIOR COMPARTMENT
Pelvic Floor
▪ Lower part is just above perineal membrane where ▪ This connection enforces urethral immobilization
CU and UVS are located against downward force exerted by increased
◦ Distal urethra abdominal pressure
▪ Extends from outer layer of urogenital diaphragm • Dorsal group of urethral ligaments have variable and
to external urethral meatus inconsistent names
▪ Primarily fibrous, directs urinary stream rather ◦ Suburethral ligament (SBUL) is preferred term
than part of continence mechanism ▪ This ligamentous component runs posterior to
urethra and forms a suburethral sling
Innervation ▪ Cleavage is present between SBUL and anterior
• Combined autonomic (sympathetic, parasympathetic) vaginal wall
and somatic input with coordination of detrusor, ▪ Extends anterolaterally to pelvic sidewall
urethral sphincter, and levator ani muscles
Endopelvic Fascia
URETHRAL SUPPORT SYSTEM • Level III fascial support (level of fusion)
◦ Corresponds to region of vagina that extends from
Components introitus to 2-3 cm above hymenal ring
• 3 components of urethral support: Urethral ligaments, ▪ Near introitus, vagina is fused laterally to levator
level III endopelvic fascia, and puborectalis muscle ani
▪ Posteriorly, it is attached to perineal body;
Urethral Ligaments
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• Ventral group of urethral ligaments includes anteriorly, it blends with urethra
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◦ At this level, there is no intervening paracolpium
pubourethral, periurethral, and paraurethral
ligaments between vagina and its adjacent structures
◦ Functional significance
• Pubourethral ligaments (PULs)
e.
▪ Level of urethral support; therefore, it is important
◦ Consist of a group of 3 distinct but related ligaments:
Proximal (PPUL), intermediate (IPUL), and distal for urinary continence
▪ Endopelvic fascia is better developed in this region,
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(DPUL)
◦ All have a similar anteroposterior orientation from providing significant support for bladder neck as
ventral urethral surface to pubic bone well as urethra
▪ Loss of normal support at bladder neck is one factor
◦ Most important are PPUL and DPUL: Play important
bg
role in suspending and maintaining female urethra in responsible for stress urinary incontinence
situ Puborectalis Muscle
◦ Proximal pubourethral ligaments (PPULs)
ko
• Arises from superior and inferior rami of os pubis
▪ 2 PPULs lie symmetrically on either side of midline • Forms sling around junction of rectum and anal canal
▪ Anchor proximal urethra and anterior surface of • Unites with puborectalis muscle of other side; does not
bladder neck to dorsal surface of symphysis pubis
oo
insert into any skeletal structure posteriorly

▪ Functionally contribute to suspension of anterior • Contributes to maintaining urethral pressure
urethral region ◦ Some of its anteromedial fibers that attach to vagina
▪ Appear to counteract opening of posterior
assist in direct elevation and support of urethrovesical
eb
vesicourethral angle during stress neck, thus affecting urethral pressure and continence
◦ Intermediate pubourethral ligaments (IPULs)
▪ Situated between PPUL and DPUL but are not
URINARY INCONTINENCE (UI)
://
clearly distinguishable from them

▪ Extend between dorsal wall of middle urethra and General Issues
lower posterior surface of symphysis pubis, helping • Urinary continence requires both normal urethral
tp
to maintain support of middle part of urethra support and sphincteric function

▪ Functionally weak, suggesting they play only a • Incontinence may be a multifactorial problem
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modest role in support ◦ Extraurethral

◦ Distal pubourethral ligaments (DPULs) ▪ Urinary fistula
▪ Extend from dorsolateral surface of distal urethra, ▪ Ectopic ureter
near the urethral meatus, to insert on lower border ◦ Urethral
of symphysis pubis ▪ Bladder/urethral abnormalities
▪ Functionally, they support and fix distal urethra ▪ Sphincteric abnormalities
• Periurethral ligament ◦ Episodic
◦ Thin ligament extending from urethra to medial ▪ Abnormal detrusor function or stress incontinence
aspects of puborectalis muscle
◦ Courses ventral to middle and proximal urethra
Terminology and Classification
• Classified by International Continence Society based
• Paraurethral ligaments
◦ Connect lateral wall of urethra to periurethral on signs, symptoms, and conditions (urodynamic
ligaments and puborectal sling, providing vital observations)
• Stress urinary incontinence (SUI)
framework for urethral support
◦ Most common type of UI in women
◦ Functionally, periurethral and paraurethral ligaments
◦ Urinary leakage with increased intraabdominal
link proximal urethra to puborectal sling
pressure (e.g., coughing, sneezing, laughing)
▪ Occurs when intravesical pressure exceeds
maximum urethral closure pressure 8
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▪Occurs in absence of detrusor contraction ▪ Localized action is separate from activity of rest of
◦ Caused by primary urethral abnormality detrusor muscle
▪ Defect in urethral support system; accounts for ▪ Surrounds anterior portion of vesical neck and
80-90% of SUI cases maintains closure
▪ Intrinsic urethral sphincteric deficiency is less ◦ Trigonal ring
common and more challenging to treat ▪ Ring of smooth muscle and elastin between
• Urge urinary incontinence (UUI) detrusor loop and urethral lumen
◦ Also called spastic or overactive bladder ▪ Also acts to keep this region of vesical neck closed
◦ Sudden urge to urinate caused by inappropriate ◦ Damaged internal sphincter manifests in patients as
contraction of detrusor muscle open vesical neck
• Mixed urinary incontinence (MUI) ▪ Patients have SUI despite normal support (termed
◦ Components of both SUI and UUI intrinsic sphincteric deficiency)
• Difficult to distinguish between SUI and UUI by history • External sphincter
alone (e.g., detrusor contraction provoked by coughing ◦ Striated muscle extending ~ 60% of length along mid
or change of position) urethra
◦ Urodynamics have been accepted as cornerstone of ◦ Lies below vesical neck
differentiation between SUI and UUI ◦ Capable of voluntary contraction
◦ Correlation between urodynamic findings and UI ◦ Damage to external sphincter can also be associated
symptoms is often poor, particularly in patients with with SUI
t
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symptoms of MUI
• History and symptoms may be further confounded by
RELATED REFERENCES
coexistent pelvic organ prolapse
◦ Organ prolapse can cause obstruction of urine 1. Bitti GT et al: Pelvic floor failure: MR imaging evaluation
e.
leakage of anatomic and functional abnormalities. Radiographics.
◦ Those with severe prolapse may actually have 34(2):429-48, 2014
2. Del Vescovo R et al: MRI role in morphological and
yn
improvement in SUI functional assessment of the levator ani muscle: use in
• Imaging plays important role in evaluation of UI patients affected by stress urinary incontinence (SUI)
before and after pelvic floor rehabilitation. Eur J Radiol.
Etiology
bg 83(3):479-86, 2014
• Urethral trauma resulting from childbearing is most 3. Farouk El Sayed R: The urogynecological side of pelvic floor
common cause MRI: the clinician's needs and the radiologist's role. Abdom
• Surgical trauma Imaging. 38(5):912-29, 2013
ko
• Loss of estrogen 4. Surabhi VR et al: Magnetic resonance imaging of female
• Aging (independent of estrogen loss) urethral and periurethral disorders. Radiol Clin North Am.
• Prolonged increased intraabdominal pressure (e.g., 51(6):941-53, 2013
oo
5. Tasali N et al: MRI in stress urinary incontinence:

persistent heavy lifting or straining, chronic coughing)
•
endovaginal MRI with an intracavitary coil and dynamic
Neurologic damage pelvic MRI. Urol J. 9(1):397-404, 2012
• Connective tissue disorders 6. Maglinte DD et al: Functional imaging of the pelvic floor.
eb
• Drugs that alter muscular tone Radiology. 258(1):23-39, 2011

• Vascular changes 7. Haylen BT et al: An International Urogynecological
Association (IUGA)/International Continence Society (ICS)
Urethral Support System Dysfunction joint report on the terminology for female pelvic floor
://
• Damage to either connective tissue elements or muscles dysfunction. Int Urogynecol J. 21(1):5-26, 2010
of this apparatus could result in SUI 8. Miller JM et al: MRI findings in patients considered high
◦ Connective tissue elements risk for pelvic floor injury studied serially after vaginal
tp
▪ Urethral supporting ligaments childbirth. AJR Am J Roentgenol. 195(3):786-91, 2010

▪ Level III endopelvic fascia 9. Bennett GL et al: MRI of the urethra in women with lower
ht
◦ Muscular elements urinary tract symptoms: spectrum of findings at static and

dynamic imaging. AJR Am J Roentgenol. 193(6):1708-15,
▪ Puborectalis muscle
2009
Sphincteric Mechanism Dysfunction 10. El Sayed RF et al: Pelvic floor dysfunction: assessment with
•
combined analysis of static and dynamic MR imaging
Sphincteric activity of urethra comes from 3 different findings. Radiology. 248(2):518-30, 2008
tissue elements; each contributes ~ 1/3 of urethral 11. El Sayed RF et al: Anatomy of the urethral supporting
closing pressure at rest ligaments defined by dissection, histology, and MRI of
◦ Smooth muscle female cadavers and MRI of healthy nulliparous women. AJR
◦ Striated muscle (external urethral sphincter) Am J Roentgenol. 189(5):1145-57, 2007
◦ Vascular elements 12. Macura KJ et al: MR imaging of the female urethra
• Abnormal sphincter function can result from deficiency and supporting ligaments in assessment of urinary
incontinence: spectrum of abnormalities. Radiographics.
of either internal sphincter (vesical neck) or external
26(4):1135-49, 2006
sphincter 13. DeLancey JO: Structural support of the urethra as it relates
• Internal sphincter to stress urinary incontinence: the hammock hypothesis.
◦ Surrounds proximal ~ 20% of urethral lumen and Am J Obstet Gynecol. 170(6):1713-20; discussion 1720-3,
contains detrusor loop and trigonal ring 1994
◦ Detrusor loop
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Pelvic Floor
URINARY BLADDER
Peritoneum
Fundus (dome) of bladder
Perivesical space (with pudendal Body of bladder

venous plexus)
Left ureteral orifice
Obturator internus muscle Trigone
Levator ani muscle Arcus tendineus fascia pelvis

Urethra
Crus of clitoris and ischiocavernosus
muscle End of round ligament
Bulb of vestibule and bulbospongiosus
muscle
Vaginal introitus
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Uterus
e.
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Bladder
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Levator ani
Obturator externus muscle
ko
Urethra
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Femoral artery and vein

://
Pectineus muscle
Obturator canal
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Levator ani muscle
(Top) Frontal illustration of the female bladder shows that it rests on the muscular floor of the pelvis and is supported by the endopelvic fascia
suspended between the arcus tendineus fascia pelvis. The dome of the bladder is covered by the peritoneum. The bladder is surrounded by a
layer of loose fat and connective tissue (the prevesical and perivesical spaces) that communicate superiorly with the retroperitoneum. (Middle)
Coronal T2WI MR of the bladder at a similar level shows the position of the bladder and urethra relative to the levator ani muscle and urogenital
diaphragm. (Bottom) Axial T2WI MR of the bladder shows the surrounding musculature and obturator canal through which the obturator nerve,
artery, and vein travel.
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INNERVATION
L4
L5
S1
S2
S3
Sciatic nerve S4
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Pudendal nerve
e.
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bg
T10-L2 sympathetic chain
ko
Inferior mesenteric ganglion
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Hypogastric nerve
(sympathetic)
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://
tp
Pelvic nerves
(parasympathetic)
Bladder (smooth muscle)
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Pelvic floor
External sphincter Pudendal nerve (somatic)
(Top) The upper component of the sacral plexus coalesces into the sciatic nerve on the ventral surface of the piriformis muscle. The lower
segment forms the pudendal nerve, which exits the pelvis through the greater sciatic foramen. It then curves around the sacrospinous ligament
to enter the perineum through the lesser sciatic foramen. The pudendal nerve is the primary innervation for the perineum and external anal
sphincter. (Bottom) Parasympathetic bladder innervation is from the S2-S4 nerve roots via the pelvic plexus. Sympathetic nerve roots originate
from thoracic T10-L2, synapse at the inferior mesenteric ganglion, and continue as the hypogastric nerve. Somatic innervations of the urogenital
sphincter muscle and striated muscles of the pelvic floor are via the perineal branch of the pudendal nerve.
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Pelvic Floor
EXTERNAL URETHRAL SPHINCTER
Urinary bladder
Upper sphincter portion of

external urethral sphincter
(EUS)
t
Vaginal wall
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Compressor urethrae
e.
Urethrovaginal sphincter
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bg
ko
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Pubic symphysis
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Bladder neck
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Upper sphincteric portion

of EUS
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Urethrovaginal sphincter
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Compressor urethrae
(Top) Graphic shows the outer striated muscle sphincter (external urethral sphincter [EUS]). It has 2 different components, an upper sphincteric
portion, and 2 lower, arch-like muscular bands. The upper sphincteric portion is composed of circularly arranged muscle fibers, thickest at the
middle of the urethra. At this level, it is a continuous ring, although relatively thin and largely devoid of muscle fibers posteriorly. The arch-
like muscular bands consist of the compressor urethrae (CU) and urethrovaginal sphincter (UVS). (Bottom) Sagittal graphic shows the overall
arrangement of the structures responsible for urinary continence. From cranial to caudal, these include (1) the bladder neck and proximal
urethra; considered the initial segment, it comprises 20% of the total urethral length, (2) the mid-urethral segment is the longest with an upper
sphincter portion and a lower CU and UVS, (3) the distal 20% of the urethra is primarily fibrous and does not contribute to continence.
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URETHRAL WALL
Transitional epithelium Superficial trigonal muscle
Deep trigone muscle
Trigonal ring Detrusor muscle
Pubovesical muscle Trigonal plate

Longitudinal smooth
muscle Crista urethralis
Circular smooth muscle

Longitudinal subepithelial
Striated urogenital vascular plexus
sphincter muscle
t
Submucosal vaginal smooth
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muscle
Vaginal mucosa
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Nonkeratinizing squamous
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epithelium
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Pubovesical muscle
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Fascia
Striated urogenital
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sphincter muscle
Circular smooth muscle Proximal subepithelial

vascular plexus
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Longitudinal smooth
muscle
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Trigonal plate
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Detrusor muscle
Submucosal vaginal smooth

muscle
Vaginal wall
(Top) Midsagittal section of the urethra shows the histologic layers. The epithelium changes from transitional epithelium in the trigone to
nonkeratinizing squamous epithelium within the distal urethra. Within the lamina propria is a rich vascular plexus that functions in maintaining
urinary continence by coapting the mucosal surfaces and creating a mucosal seal. The lamina propria is also rich in collagen and elastic
components. This is surrounded by 2 layers of smooth muscle, an inner longitudinal and outer circular layer. The longitudinal layer primarily
functions to shorten the urethra during micturition. Striated muscle surrounds the smooth muscle layers. (Bottom) Layers of the urethra, near the
junction of the proximal and middle 1/3, are shown in this cross section. The urethra undergoes marked histologic and morphologic changes
with aging. Striated muscle decreases and is replaced by connective tissue. The vascular plexus is also affected by decreased estrogen levels. All
of these changes can adversely affect continence.
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URETHRAL MR
Striated muscle layer Smooth muscle layer
Pubic bone
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Smooth muscle and submucosa Striated muscle
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Urethral lumen
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Detrusor muscle
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Urethra
(Top) Sagittal T2WI MR shows a normal female urethra. The outer low-signal layer corresponds to the outer striated muscle, which is most
prominent in the mid urethra on the ventral side of the urethral wall; it may be thinned or incomplete posteriorly. It may also be less prominent in
postmenopausal women. The inner higher signal is the smooth muscle (longitudinal and circular) layers and vascular submucosa. (Middle) More
layers can be appreciated in the axial plane. The urethra has a characteristic target-like appearance with 4 concentric rings on T2WI: An outer
ring of low signal intensity (outer striated muscle), a middle layer of higher signal intensity (smooth muscle and submucosa), an inner ring of low
signal intensity (mucosa), and a high signal intensity zone in the center (intraluminal secretions &/or urine). (Bottom) Coronal T2WI shows the
urethra at the level of the bladder neck.
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URETHRAL LIGAMENTS
Proximal pubourethral ligament
Intermediate pubourethral ligament
Pubic bone
Distal pubourethral ligament

Anterior and posterior urethral walls
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Pubic bone
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Pubic bone
(Top) Photograph of a sagittal section from a female cadaver shows the anatomic dissection of the pubourethral ligaments (PUL). The 3 PULs
course anteroposterior from the pubic bone to the anterior urethral wall and include the proximal (PPUL, pink arrow), intermediate (IPUL, blue
arrow), and distal (DPUL, green arrow) ligaments. Each ligament connects different portions of the ventral urethral surface to the pubic bone on
either side of the symphysis pubis. (Reprinted with permission from the American Journal of Roentgenology.) (Middle) Sagittal proton density MR
of the same cadaver shows the same 3 ligaments: PPUL (pink arrow), IPUL (blue arrow), and DPUL (green arrow); all are of intermediate signal
intensity. (Reprinted with permission from the American Journal of Roentgenology.) (Bottom) Sagittal T2-weighted turbo spin-echo MR in a 28-
year-old female volunteer shows the PPUL (pink arrow) with its attachment to the back of the pubic bone at the junction of its upper 2/3 and
lower 1/3. The periurethral ligament is also seen. (Reprinted with permission from the American Journal of Roentgenology.)
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URETHRAL LIGAMENTS

Symphysis pubis

Urethra Periurethral ligament
Bladder
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Urethra
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Vagina
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Rectum
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Proximal pubourethral ligaments

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(Top) Photograph shows the top of a cadaveric dissection of the female urethral ligaments. The symphysis pubis is cut away in the midline to
show the proximal pubourethral ligament (PUL) (pink arrow), intermediate PUL (blue arrow), and distal PUL (green arrow). Another ligament
in the ventral group is the periurethral ligament (red diamonds), which courses from the medial aspect of the puborectalis muscle to the mid
urethra. The suburethral ligament (yellow arrow) from the dorsal group runs posterior to the urethra, forming a suburethral sling. (Reprinted
with permission from the American Journal of Roentgenology.) (Middle) Axial proton density MR of the same cadaver shows a high-signal
marker placed on the periurethral ligament. (Reprinted with permission from the American Journal of Roentgenology.) (Bottom) Axial T2WI TSE
MR shows the proximal PUL (pink arrows), periurethral ligament (red diamonds), and suburethral ligament (yellow arrows). (Reprinted with
permission from the American Journal of Roentgenology.)
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GRID FOR URETHRAL LIGAMENT EVALUATION
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Eight consecutive axial T2WI MR images on a normal nulliparous woman shows how to apply a grid system for analyzing and reporting findings.
First, identify the most cranial image on which arcuate pubic ligament can be visualized and define that image as image A or 0. Next, number
sequential axial images cephalad to image 0 with positive numbers and those caudad, with negative numbers as shown. There is significant
visibility differences and anatomic variation between patients. A systematic approach such as this will help familiarize with anatomically complex
areas.
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URETHRAL SUPPORT SYSTEM
Superficial external anal sphincter
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Superficial transverse perineal muscle
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Perineal body

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Right arcus tendineus fascia pelvis Left arcus tendineus fascia pelvis
(ATFP) (ATFP)
Urethra
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(Top) This is the 1st of 8 axial T2WI MR images shown in the grid, which allows evaluation of the entire urethral support system, including
the urethral ligaments, level III endopelvic fascia, and puborectalis muscle. According to the grid, this is image -1. At this level, the superficial
external anal sphincter is visualized, which is seen as 2 parallel muscle fibers running from anterior to posterior. (Middle) According to the grid,
this is image A or 0, which is the most cranial image on which arcuate pubic ligament can be visualized. The superficial transverse perineal
muscle extends medially and posteriorly to insert on the perineal body and external anal sphincter. (Bottom) This is level +1, which is just cranial
to the arcuate pubic ligament. The arcus tendineus fascia pelvis arises from the pubic symphysis and joins with the arcus tendineus levator ani. It
provides lateral anchoring sites for the anterior vaginal wall and support for the urethra.
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Right ATFP
Left ATFP
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Puborectalis muscle
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Proximal pubourethral ligaments

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(Top) On axial level +2, the periurethral ligaments are first seen. (Middle) Axial level +3 is shown. The periurethral ligaments are 1 of the group
of ventral ligaments. They course ventrally to the urethra and insert on the medial aspect of the puborectalis muscle. (Bottom) A thinner cut at
level +3 better shows the suburethral ligament. This is a dorsal ligament, which is located posteriorly between the urethra and vagina. It forms a
suburethral sling and extends anterolaterally to the pelvic sidewall. The origin of the proximal pubourethral ligaments can be visualized along the
posterior pubic symphysis. These ligaments are better seen on axial oblique images.
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Pelvic Floor
Urethra
Vagina
Anal canal
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Bladder base
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Urethra
Vagina
Puborectalis muscle
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Urethra
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(Top) Axial level +4 is through the mid urethra, where the external urethral sphincter is best visualized. It has a low-signal striated muscle layer
that is thickest anteriorly. Near the bladder neck, fibers of the muscular wall of the urethra intermingle with fibers of the periurethral ligament.
(Middle) Axial level +5 is just entering the bladder base. It is also the level of transition between the puborectalis muscle and the iliococcygeus
muscle. (Bottom) Axial level +6 is the highest level in this series.
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Puborectalis muscle
Obturator internus
Tip of coccyx
(Top) Three axial T2WI MR images from a normal volunteer shows the upper-most image with the arcuate pubic ligament (APL); therefore, this is
designated as image A or 0. (Middle) This image through axial level +1 shows both the periurethral ligament (ventral group) and the suburethral
ligament (dorsal group). The arcus tendineus fascia pelvis is seen at its attachment site at the pubic symphysis. (Bottom) Axial image shows
level +3. In addition to the periurethral ligament, a small portion of the pubourethral ligament can be seen. Because of its oblique course, it is
inconsistently visualized in the axial plane.
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URODYNAMICS
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(Top) Schematic diagram shows the basics of urodynamics. It provides objective evidence about lower urinary tract function. Subtracted
cystometry measures the pressure exerted in the bladder by the detrusor muscle. Bladder catheter measures the total intravesical pressure
(Pves). Intrarectal catheter measures intraabdominal pressure (Pabd). Detrusor pressure (Pdet) = Pves - Pabd. Fluid volume infused and pressure
measurement are recorded continuously. (Bottom) Graphic represents a urethral pressure profile study, a test to measure urethral closure
pressure (Pclose). Because continence requires the pressure in the urethra (Pure) to be higher than the pressure in the bladder (Pves), measuring
the pressure differential between the 2 provides quantitative assessment of sphincteric integrity. Pclose = Pure - Pves. The presence of a negative
pressure transmission across the proximal urethra indicates stress urinary incontinence. Pclose is measured by slowly pulling a pressure-sensitive
catheter through the urethra from the bladder.
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STRESS URINARY INCONTINENCE: INTRINSIC SPHINCTERIC DEFICIENCY
Urinary bladder
Bladder neck
Urethra
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Bladder neck
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Urethra
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Bladder neck
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Urethra
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Cough
Bladder filling
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Cough
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No change in detrusor
pressure
Urine leak
Transperineal ultrasound evaluation of a patient with urinary incontinence shows a sagittal view of the urine-filled bladder, bladder neck, and
symphysis pubis. Images at rest revealed intrinsic malfunction of the urethral sphincter characterized by an open vesical neck. During straining
and withholding (active contraction of the pelvic floor), the bladder neck was persistently open with funneling, without the expected narrowing
during withholding. The patient had urine leakage throughout the exam. Subtracted cystometrogram shows a stable bladder with no rise in
detrusor pressure during filling. When a cough is elicited, there is a sharp, isolated pressure spike on the intravesical and intraabdominal tracings,
but there are no spikes on the subtracted detrusor tracing. The presence of leakage occurring with coughing confirms that this is stress urinary
incontinence due to ineffective urethral closure rather than detrusor overactivity.
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URGE URINARY INCONTINENCE: DETRUSOR INSTABILITY
Urinary bladder
Bladder neck
Urethral wall
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Bladder neck
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Urethral wall
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Bladder neck
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Urine leakage
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Cough
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Cough
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Increased detrusor
pressure without
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No change in detrusor
increased abdominal
pressure
pressure
Urine leak
Transperineal evaluation of a patient with urinary incontinence shows a sagittal view of the urine-filled bladder, bladder neck, and symphysis
pubis. Note the relatively high position of the bladder neck. The bladder neck does not descend and remains above the inferior margin of the
pubis symphysis during maximum straining. During the examination, there was a sudden descent and opening of the bladder neck accompanied
by passage of urine, which the patient was unable to stop. Subtracted cystometrogram shows detrusor instability. There is a normal sharp spike
in vesical and abdominal pressures during coughing with the subtracted detrusor pressure remaining stable. However, there was a spontaneous
increase in detrusor pressure without an increase in the abdominal pressure, indicating that the pressure originated from the detrusor muscle.
These findings are consistent with urge urinary incontinence related to detrusor muscle instability.
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URETHRAL CONTINENCE
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Flow chart shows a detailed scheme of the urethral continence structures, including the extrinsic supporting structures (ligaments, endopelvic
fascia level III, and puborectalis muscle), as well as the urethra itself, including the mucosal membrane and urethral wall. The chart below lists
causes of intrinsic sphincter deficiency, the most common being trauma from childbirth.
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Pelvic Floor
URINARY INCONTINENCE
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Flow chart illustrates a scheme to help in the classification of urinary incontinence. Extraurethral causes should be ruled out first. Urethral
incontinence may result from an abnormal bladder, caused by either a detrusor muscle abnormality or low bladder compliance, or a structural
abnormality involving the urethra, either with its support system or an intrinsic sphincter deficiency.
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Pelvic Floor ANTERIOR COMPARTMENT IMAGING
Key Facts
Normal Urethral Support System Urethral Support System Defects
• 3 key elements • Ligaments
◦ Urethral ligaments ◦ Manifest as discontinuity or architectural distortion
◦ Endopelvic fascia (level III fascial support) • Level III endopelvic fascia
◦ Puborectalis muscle ◦ Most common of anatomic abnormalities
• Ligaments ◦ Medial displacement of vaginal wall and endopelvic
◦ Dorsal and ventral groups play important role in fascia from its normal attachment
suspending urethra ◦ Fat in prevesical space extends laterally against
• Level III endopelvic fascia supports mid urethra and sagging detached lower 1/3 of anterior vaginal wall
maintains the following relationships (drooping mustache sign)
◦ Central positioning of mid urethra • Puborectalis muscle
◦ Small, symmetric-appearing space of Retzius ◦ Detachment or atrophy
◦ Preserved H-shaped vagina Diagnostic Checklist
• Puborectalis muscle
• Exam should include both static and dynamic
◦ Symmetric muscle sling around rectum
evaluation
◦ Normal activity of this muscle influences stiffness of • Imperative report is complete and specifically
t
urethral supporting structures
mentions all 3 urethral supporting structures
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(Left) Axial T2WI MR of a
woman with normal urethral
support system shows the
periurethral ligament ,
bg
which is seen ventral to the
urethra coursing between
the medial borders of
ko
the puborectalis muscle.
(Right) Axial T2WI MR in a
woman with stress urinary
incontinence (SUI) shows
oo
discontinuity of the lateral

attachments of the periurethral
ligament . Note that the
eb
space of Retzius is normal in

size, the vagina maintains its
normal shape, and the urethra
is still midline, indicating that
://
the level III fascia is still intact.

tp
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woman with normal level
III endopelvic fascia shows
a small symmetric space of
Retzius . The vagina has
a normal H-shape and
the urethra is midline. (Right)
Axial T2WI MR of a woman
with SUI shows the drooping
mustache sign . The space
of Retzius is abnormally
widened laterally, "drooping"
around the urethra, which is
shifted slightly to the right.
There is loss of H-shaped
vagina , which now appears
flattened. These findings
indicate disruption of the level
8 III fascia.
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ANTERIOR COMPARTMENT IMAGING
Pelvic Floor
IMAGING EVALUATION – Drawn from inferior border of pubic symphysis to
last coccygeal joint
Imaging Modalities – Represents approximate level of pelvic floor
• MR: Modality of choice muscles
◦ Dynamic and static imaging both required for ▪ Midsagittal plane measurements
complete evaluation – H-line: Inferior border of symphysis pubis to
◦ Can do high-resolution endocavitary scan anorectal junction
(endourethral, endovaginal, endorectal) – M-line: Perpendicular from PCL to posterior end
• Ultrasound of H-line
◦ Transperineal or transvaginal – Levator plane angle (LPA): Between levator plane
• Conventional cystourethrogram and PCL
▪ Axial plane measurement
– Width of levator hiatus (WLH): Between
MR TECHNIQUES puborectalis muscle slings
▪ Coronal plane measurement
General Background – Iliococcygeus angle (ILCA): Between
• Thorough history should be obtained and complete iliococcygeus and transverse plane of pelvis
instructions regarding exam given to every patient
• No specific preparation is required before imaging Endocavitary MR
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of urethral supporting ligaments but often > 1 • Can be done for detailed evaluation of urethral
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compartment is involved sphincter muscle
• Recommend full preparation and complete study ◦ Requires high-resolution endocavitary imaging, small
◦ Bladder should be comfortably full without field of view, and high imaging matrix
e.
overdistention • Intraurethral imaging can be performed with 14-F
▪ Void 2 hours prior to exam internal MR coil
◦ Opacification of rectum with ultrasound gel is ◦ Should be placed using sterile technique, like any
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minimal requirement with opacifaction of vagina as other urethral catheter
optional • Endovaginal and endorectal imaging can be performed
as well
Static MR
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• Imaging protocol
• Imaging protocol ◦ T2-weighted images are obtained in axial, sagittal, and
◦ No standardized protocol for static MR of patients coronal planes
ko
with pelvic floor dysfunction (PFD) ▪ Slice thickness: 2.5-3.0 mm
◦ Sample PFD protocol ▪ Field of view is 5-6 cm for intraurethral imaging
▪ Static images of pelvis acquired in 3 planes using ▪ Field of view is 12-14 cm for endovaginal and
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T2-weighted turbo spin-echo (TSE) sequences endorectal imaging

▪ TR/TE: 5,000/132; number of signals acquired: 2;
flip angle: 90°
▪ Field of view (FOV): 240-260 mm; slice thickness: 5 MR OF URETHRAL SUPPORT SYSTEM
eb
mm; gap: 0.7 mm; matrix: 512 x 512

◦ Specific evaluation of urethral ligaments for women Normal Urethral Support System
with stress urinary incontinence (SUI) • 3 key elements
://
▪ Thinner slices (2 mm thick) with FOV centered on ◦ Urethral ligaments

urethral ligaments ◦ Endopelvic fascia (level III fascial support)
▪ Sagittal plane is essential for evaluation of female ◦ Puborectalis muscle
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urethral supporting ligaments • Evaluation of urethral ligaments is a meticulous process

– May see craniocaudal extension of certain ◦ Assess 2 main groups of ligaments: Ventral and dorsal
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urethral ligaments in sagittal plane urethral ligaments

– Coronal plane is least helpful for urethral ▪ Ligaments have a relatively hypointense signal
supporting ligaments intensity on T2WI
Dynamic MR Ventral Urethral Ligaments
• Diagnostic criteria • Pubourethral ligaments (PULs)
◦ Best evaluated on midsagittal true fast-imaging ◦ Variably visualized depending on slice thickness,
dynamic evacuation sequences plane of section, and patient anatomy
◦ On sagittal, axial, and coronal images during ◦ Axial T2WI
maximum straining ▪ Paired proximal PULs are 2 low signal intensity
◦ Pelvic organ prolapse (POP) and SUI are evaluated on linear structures extending from proximal urethra
sagittal plane to pubic bone in anteroposterior direction
▪ Pelvic organ descent is measured and graded ▪ Intermediate PULs (mid urethra) are functionally
▪ Urinary incontinence recorded when loss of urine weak and often not seen
through urethra is visualized at maximum straining ▪ Distal PUL extends from distal urethra to posterior
◦ 5 measurements of support structures taken surface of pubic symphysis
▪ Pubococcygeal line (PCL) is important reference for ◦ Sagittal T2WI
midsagittal measurements
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▪ Proximal PUL seen as linear structure of • Distortion

intermediate to low signal intensity ◦ Internal architectural changes &/or waviness of
▪ Intermediate PUL and distal PUL not visualized ligaments
reliably in this plane
• Periurethral ligament
Level III Endopelvic Fascial Defect
◦ Often easiest ligament to see on MR • Most common anatomic abnormality
• Assessed at level of proximal urethra and bladder neck
◦ Axial T2WI
• Defect defined as medial displacement of vaginal
▪ Appears as sling-like structure anterior to urethra
wall and endopelvic fascia from its normal line of
▪ Proximal PUL is attached to ventral aspect of
attachment to pelvic sidewall at arcus tendineus fascial
periurethral ligament
pelvis (ATFP)
◦ Axial oblique balanced fast field echo (BFFE)
• Detachment of fascia from ATFP will result in loosening
▪ Attaches to medial aspect of puborectalis muscle on
of tissues of fascia that span between the 2 arcus
both sides
tendineae
• Paraurethral ligaments
◦ As attachment to lateral pelvic wall is lost, urethra
◦ Axial MR
may no longer be in position where muscles can exert
▪ Tiny thin ligaments force that counterbalances abdominal pressure
▪ Visualized as obliquely oriented linear structures of • Recognizable by drooping mustache sign
◦ Fat in space of Retzius forms mustache-like appearance
▪ Extends from lateral wall of urethra to periurethral
◦ Central midpoint of narrowing with abnormally
t
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ligaments
widened lateral spaces
Dorsal Urethral Ligaments • Pathophysiology of drooping mustache sign
• Suburethral ligament ◦ Anterior vaginal wall has been detached from ATFP
◦ Fat in prevesical space extends laterally against
e.
◦ Should be evaluated at level of proximal and middle
urethra sagging detached lower 1/3 of anterior vaginal wall
◦ Axial T2WI ◦ Detachment is almost always bilateral, uncommonly
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▪ Urethra lies on supporting shelf-like layer located unilateral
ventral to anterior vaginal wall Puborectalis Muscle Abnormalities
▪ This supporting layer consists of low signal
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• Normal activity of these muscles influences tension of
intensity ligamentous structure anterior to a high
urethral supporting structures
signal intensity layer intimately related to anterior
◦ Injury results in loss of upward forces provided by
vagina wall
these muscle attachments
ko
▪ Ligamentous part extends anterolaterally toward • Detachment from its origin

lateral pelvic sidewalls at site of origin of levator ani
◦ Identified by discontinuity of its attachment to pubic
from obturator internus muscles
bone
oo
◦ May be best seen on axial fat-suppression MR

▪ May be either unilateral or bilateral
▪ Suburethral ligament runs retrourethral, forming a • Muscle fibers disruption
suburethral sling, with plane of cleavage between
◦ Recognizable by discontinuity of normal symmetric
eb
ligament and anterior vaginal wall

appearance of muscle sling
Endopelvic Fascia • Atrophy, either focal or generalized
• Level III endopelvic fascia
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◦ Supports mid urethra

◦ Fascia not directly visualized but integrity is inferred
ULTRASOUND
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by normal appearance of structures being supported Imaging Techniques

◦ Criteria to infer intact level III endopelvic fascia • Transducer (either transvaginal or curved array
▪ Central positioning of mid urethra
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transducer) is placed on perineum against symphysis

▪ Small symmetrical appearance of space of Retzius pubis
▪ Preserved butterfly or H-shaped vagina ◦ Do not exert undue pressure on perineum as it may
Puborectalis Muscle obstruct development of pelvic organ descent
• Midsagittal view includes symphysis anteriorly, urethra
• Best evaluated in axial plane
and bladder neck, vagina, cervix, rectum, and anal
◦ Similar low signal intensity to other skeletal muscle
canal
◦ Normally shows bilateral symmetrical muscle slings
◦ If field of view is wide enough, the levator plate, a
with no gross evidence of defect or scarring
hyperechoic area posterior to anorectal junction, can
◦ Attachment to pubic bone can be traced
be seen
anterolaterally on both sides
• Parasagittal or transverse views yield additional
information on urethral integrity and puborectalis
URETHRAL SUPPORT SYSTEM DEFECTS muscle
Urethral Ligament Abnormalities Diagnostic Criteria

• Bladder neck and proximal urethra
• Defects
◦ Bladder neck position relative to inferior margin of
◦ Discontinuity of ligaments with visualization of torn
symphysis pubis is noted in midsagittal plane
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▪ Measurements are taken at rest and maximal – Posterior vesicourethral angle (PVUA) beyond
Valsalva; difference yields bladder neck descent 100° during straining indicates urethral
▪ On Valsalva, proximal urethra rotates in hypermobility
posteroinferior direction • Now less commonly performed; provides only
▪ Retrovesical angle (RVA) is drawn from posterior silhouette view of contrast-filled organs
bladder wall through urethral lumen, with normal
resting range: 90-120°
◦ Normal vs. abnormal US findings DIAGNOSTIC CHECKLIST
▪ No consensus definition of normal bladder neck
descent, although cutoffs of 20, 25, and 30 mm
• Evaluation of urethral supporting structures requires
have been proposed to define hypermobility
meticulous systematic approach
– Widening of RVA > 160° is also suggestive
◦ Often > 1 support structure is damaged
▪ In SUI, funneling of internal urethral meatus at
• Evaluation of SUI requires both static and dynamic MR
bladder neck may occur on Valsalva or even at rest
sequences
▪ Funneling is often (but not necessarily) associated
with leakage Reporting Tips
▪ Marked funneling is associated with poor urethral • Imperative that report is complete and specifically
closure pressures mentions all 3 urethral supporting structures
◦ Doppler
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▪ Color or power Doppler can assess urethral
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vascularity, which is believed to contribute to SELECTED REFERENCES
continence 1. American Urogynecologic Society and American College
▪ Urethral vasculature differs along its entire length; of Obstetricians and Gynecologists: Committee opinion:
e.
mid urethra (rhabdosphincter) has greatest flow evaluation of uncomplicated stress urinary incontinence
▪ In SUI, urethral perfusion appears significantly in women before surgical treatment. Female Pelvic Med
yn
reduced; however, clinical value of assessing Reconstr Surg. 20(5):248-51, 2014
urethral vascularity by endocavitary probe has yet 2. Bitti GT et al: Pelvic floor failure: MR imaging evaluation
to be determined of anatomic and functional abnormalities. Radiographics.
34(2):429-48, 2014
◦ Levator ani injuries
bg
3. Del Vescovo R et al: MRI role in morphological and
▪ Defects are visualized most clearly on maximal functional assessment of the levator ani muscle: use in
pelvic floor muscle contraction patients affected by stress urinary incontinence (SUI)
▪ Bilateral defects are more difficult to detect because before and after pelvic floor rehabilitation. Eur J Radiol.
ko
there is no normal side for comparison 83(3):479-86, 2014

▪ On axial plane, hiatal distension (WLH) on Valsalva 4. Farouk El Sayed R: The urogynecological side of pelvic floor
is evaluated MRI: the clinician's needs and the radiologist's role. Abdom
oo
Imaging. 38(5):912-29, 2013

– Hiatal enlargement ≥ 25 cm² on Valsalva is
5. Lammers K et al: Correlating signs and symptoms with
defined as "ballooning" in young nulliparous pubovisceral muscle avulsions on magnetic resonance
women imaging. Am J Obstet Gynecol. 208(2):148, 2013
eb
◦ Look for other anomalies such as cystocele and 6. Surabhi VR et al: Magnetic resonance imaging of female
urethral diverticulum urethral and periurethral disorders. Radiol Clin North Am.
51(6):941-53, 2013
://
7. Tasali N et al: MRI in stress urinary incontinence:

CYSTOURETHROGRAPHY (CUG) endovaginal MRI with an intracavitary coil and dynamic
pelvic MRI. Urol J. 9(1):397-404, 2012
tp
Technique and Diagnostic Criteria 8. Maglinte DD et al: Functional imaging of the pelvic floor.
• Performed primarily to detect cystoceles and Radiology. 258(1):23-39, 2011
urethrovesical junction mobility 9. Haylen BT et al: An International Urogynecological
ht
Association (IUGA)/International Continence Society (ICS)

• Termed cystoproctography when combined with
joint report on the terminology for female pelvic floor
evacuation proctography dysfunction. Int Urogynecol J. 21(1):5-26, 2010
• Lateral fluoroscopy at rest and during maximum 10. Miller JM et al: MRI findings in patients considered high
straining risk for pelvic floor injury studied serially after vaginal
◦ Differentiates between bladder neck and base descent childbirth. AJR Am J Roentgenol. 195(3):786-91, 2010
▪ Bladder base descent is defined by descent below 11. Bennett GL et al: MRI of the urethra in women with lower
inferior margin of pubic symphysis urinary tract symptoms: spectrum of findings at static and
▪ Bladder neck (urethrovesical junction mobility) dynamic imaging. AJR Am J Roentgenol. 193(6):1708-15,
2009
– Evaluated in relation to PCL or small radiopaque 12. El Sayed RF et al: Pelvic floor dysfunction: assessment with
intraurethral tube combined analysis of static and dynamic MR imaging
– Descent > 1 cm is indicative of hypermobility findings. Radiology. 248(2):518-30, 2008
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woman with a normal urethral
support system shows the
suburethral ligament .
a woman with SUI shows
bilateral detachment of the
suburethral ligament .
The ligament as a whole is
subluxed backward. Also note
the abnormal configuration of
the Retzius space (drooping
mustache) and loss of the
H-shaped vagina, indicating
that there is also disruption of
the level III endopelvic fascia.
t
It is important to report all of
ne
these findings as it may affect
treatment planning.
e.
yn
the normal insertion of the
puborectalis muscles onto
the posterior pubic symphysis
bg
. Some anteromedial fibers
attach to the vagina and help
support the urethrovesical
ko
neck. (Right) Axial T2WI MR

of a woman with SUI shows
that the right puborectalis
oo
muscle is thinned and

somewhat wavy but inserts
normally on the pubic
symphysis . The left muscle
eb
sling is detached from the

pubic bone with loss of normal
support for the left side of the
vagina .
://
tp
ht

a woman with SUI shows
detachment of the urethral
supporting ligaments,
including the suburethral &
periurethral ligaments with
retraction to the midline. There
is also a drooping mustache
sign & a flattened vagina.
(Right) Another image in the
same case shows disruption
of muscle fibers in the
right puborectalis muscle. The
report should state that this is
a complex case with defects
involving the suburethral and
periurethral ligaments, level
III endopelvic fascia, & right
8 puborectalis muscle.
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Pelvic Floor
(Left) Sagittal balanced fast field
echo (BFFE) MR at maximal
straining in a woman with SUI
shows no bladder neck or other
organ descent below the PCL
(red line). (Right) Axial T2WI
MR of the same woman shows
asymmetric fascia detachment
on the left side (appears
as 1/2 a drooping mustache)
with retraction of the vaginal
wall toward the midline but
without flattening. The final
report should state that dynamic
MR sequences showed no POP
or muscle weakness, whereas
static MR images revealed left
t
ne
asymmetric level III endopelvic
fascial defect.
e.
yn
(Left) Sagittal BFFE MR of a
woman with SUI at maximal
straining shows no evidence of
bg pelvic floor weakness. (Right)
Axial T2WI MR of the same
woman at the level of mid
urethra shows that the right
ko
puborectalis is detached .
Compare this to the normal
attachment to the pubic
oo
symphysis on the opposite side

. The final report in such a
case should state that dynamic
MR sequences revealed no Pelvic
eb
organ prolapse (POP) or muscle

weakness. The static MR images
revealed detachment of the right
puborectalis sling from its bony
://
attachment.
tp
ht
(Left) Sagittal BFFE MR at

maximal straining in a woman
with SUI shows the bladder
base, cervix and anorectal
junction descending below the
PCL and an anterior rectocele
. Urine loss is evident.
(Right) Axial T2WI MR of the
same woman shows a defect of
the right endopelvic fascia with
loss of the normal H-shape of
the vagina on that side . The
suburethral ligament is also torn
bilaterally . These cases are
often complex and all findings
need to be reported.
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(Left) Sagittal graphic shows

a curved array ultrasound
transducer on the perineum
angled along the long axis
of the urethra, as indicated.
(Right) Sagittal ultrasound
shows the urethra , bladder
, and vagina . Ultrasound
can be used to evaluate the
urethra both at rest and during
Valsalva to look for bladder
base descent. (From IA:
Ultrasound.)
t
ne
e.
yn
(Left) Sagittal transperineal
shows normal flow within
the periurethral arteries
bg
with normal low-resistance
flow. (From IA: Ultrasound.)
(Right) Color Doppler US
ko
of the urethral wall in a

woman complaining about
SUI displays significantly
oo
reduced urethral perfusion.

The subepithelial vascular
plexus plays an important role
in maintaining urethral closure
eb
at rest. Decreased vascularity

is thought to be a contributing
factor to SUI.
://
tp
ht
(Left) Using a 3D probe, the

data set can be manipulated
to show an axial plane through
the mid urethra as shown.
(Right) Generated 3D image
shows that the urethra is
midline and the vagina has
a normal H-shape, indicating
that the endopelvic fascia
is intact. The iliococcygeus
muscle and rectum
are also well seen. (From IA:
Ultrasound.)
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Pelvic Floor
(Left) Sagittal transperineal
ultrasound of the urethra shows
the retrovesical angle at rest. The
distance between the inferior
edge of the symphysis pubis
(blue line) and the bladder neck
(green line) can be measured.
(Right) With Valsalva, the
proximal urethra rotates in a
posterior inferior direction,
widening the retrovesical angle
with descent of the bladder
neck. Descent > 20-30 mm is
considered abnormal and can
be seen with SUI. (From IA:
Ultrasound.)
t
ne
e.
yn
(Left) Composite image shows
a urethral diverticulum on
transperineal ultrasound. It is
bg important to note that urinary
incontinence may be caused by
structural abnormalities such as
fistulae, ectopic ureteroceles,
ko
and urethral diverticula.

(Right) Radiograph taken
during cystourethrography in a
oo
patient complaining of urinary

incontinence shows a Foley
balloon inflated within this
very large diverticulum.
eb
://
tp
ht
(Left) Coronal T2WI MR in a 39-

year-old woman complaining
of post-void dribbling, a
classic history for a urethral
diverticulum, shows a high-signal
fluid collection on either
side of the urethra. (Right) Axial
shows that the diverticulum has a
horseshoe configuration and
completely surrounds the urethra
. MR provides excellent soft
tissue contrast and anatomic
detail and is the modality of
choice for evaluating urinary
incontinence.
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Pelvic Floor OVERVIEW OF THE MIDDLE COMPARTMENT
▪ Acts as platform against which upper vagina and

TERMINOLOGY other pelvic viscera are compressed during ↑ in
Definitions intraabdominal pressure
• ▪ Subluxation of levator plate causes it to act like a
Middle compartment includes vagina, uterus, and their
supporting structures slide along which rectum and upper genital tract
◦ Weakness of support structures results in pelvic organ may descend with ↑ intraabdominal pressure
prolapse (POP) Vaginal Support
▪ True prolapse is complete organ eversion; however,
• Iliococcygeus muscle and 3 levels of fascial support
term is commonly used to generically describe any ◦ Level I (suspension) is at upper 2-3 cm of vagina
degree of pelvic organ descent ▪ Cardinal-uterosacral ligament complex
◦ Anterior vaginal wall (AVW) prolapse
◦ Level II (attachment) corresponds to middle portion
▪ Cystocele
of vagina
▪ Apical or uterine prolapse
▪ Lateral connections with arcus tendineus fasciae
◦ Posterior vaginal wall (PVW) prolapse
pelvis (ATFP)
▪ Enterocele
◦ Level III (fusion)
▪ Rectocele
▪ Attachment to perineal membrane anteriorly and
▪ Perineal descent without rectal prolapse
perineal body posteriorly
◦ Vaginal vault prolapse (VVP)
AVW Support
t
ne
NORMAL SUPPORT SYSTEM • Levels I and II support bladder
• Level III supports urethra
Uterocervical Support
• Uterus is supported by pelvic fascia, ligaments, and PVW Support
e.
levator ani muscle • Level I: Posterior vaginal suspension
• Endopelvic fascia • Level II: Midportion of posterior vaginal wall is
yn
◦ Connective tissue of endopelvic fascia forms a attached to inner surface of pelvic diaphragm by sheet
continuous unit supporting pelvic organs of endopelvic fascia that courses along lateral rectal
▪ Paracolpium refers to connective tissue that margin
◦ Along these fascial sheets, dorsally directed tension
attaches vagina to pelvic walls
bg
▪ Parametria includes fascial condensations is generated → PVW on each side of rectum (vaginal
including broad, cardinal, and uterosacral sulcus)
ligaments ▪ These paired sheets of endopelvic fascia are
ko
• Ligaments sometimes called rectal pillars

◦ Cervix is anchor for many important ligaments, ◦ Prevent ventral movement of posterior vaginal wall
acting as a "keystone" for support system ◦ Defects in endopelvic fascia between PVW and pelvic
oo
▪ After hysterectomy, this support is lost, increasing diaphragm results in significant destabilization of
risk for prolapse posterior vagina at level II
◦ Transverse cervical (cardinal) ligament extends • Level III: PVW support
eb
laterally ◦ Distal vagina is supported by dense connective tissue

◦ Uterosacral ligaments extend posteriorly of perineal body
◦ Broad ligaments and round ligaments of uterus ◦ When distal rectum is subjected to ↑ downward force,
://
play minor role in supporting uterus as they are lax fibers of perineal membrane become tight and resist
structures further displacement
▪ Uterus can be pushed down for considerable
tp
distance before these ligaments become stretched STRUCTURAL DEFECTS LEADING TO POP
• Fascia
AVW Prolapse
ht
◦ Anteriorly, pubocervical fascia (PCF) and ligaments

• Types and classification of cystocele
extend from posterior surface of pubis to cervix
▪ Gives support to bladder ◦ Central vertical defect
◦ Posteriorly, rectovaginal fascia inserts into perineal ▪ Damage of mid pubocervical fascia → distension
body, levator plate, and uterosacral ligament cystocele

• ◦ Lateral paravaginal defects
Levator ani muscle
◦ Medial edges of anterior segments of muscle are ▪ Separation of pubocervical fascia along
attached to cervix by pelvic fascia anterolateral vaginal wall from arcus tendineus
◦ Some fibers insert into perineal body fasciae pelvis → displacement (traction) cystocele
◦ Together with pelvic fascia on its upper surface, resists ◦ Proximal transverse defect
▪ Separation of pubocervical fascia from ring of fascia
↑ in intraabdominal pressure transmitted downward
into pelvis about cervix → high cystocele
• ◦ Distal transverse defect
Muscular levator plate
◦ Formed by fusion of right and left bellies of levator ▪ Separation of pubocervical fascia from pubis → low
ani muscle behind rectum and anterior to coccyx cystocele

▪ Provides indirect support for upper genital tract • Apical prolapse
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OVERVIEW OF THE MIDDLE COMPARTMENT
Pelvic Floor
◦ Damage to upper suspensory fibers of paracolpium
results in descent of uppermost area of posterior
PATHOPHYSIOLOGY OF POP
vaginal wall Factors Contributing to POP
◦ This defect is most closely associated with uterine/ • Vaginal delivery is greatest initiating factor in
vaginal vault prolapse &/or enterocele development of POP
◦ Women who had ≥ 4 vaginal deliveries have 12x
PVW Prolapse
• Structural defects are not as uniform or constant as greater risk of genital prolapse
◦ Direct damage to endopelvic fascial support system,
those seen in pubocervical fascial defects
◦ Observed mainly in patients with rectocele vaginal walls, muscles, and nerves of pelvic floor
• ◦ Episiotomies &/or lacerations of perineal musculature
Location of defects
◦ Distal transverse separation immediately above • Advancing age
• Neuromuscular disorders
attachment to perineal body
◦ Proximal transverse separation from fascial ring ◦ Include conditions that affect spinal cord pathways
about cervix and pelvic nerve roots, which → flaccid paralysis of

◦ Other less common defects between distal and pelvic floor muscles and POP
▪ Muscular dystrophy, spina bifida, and
proximal
▪ Midline vertical defect meningomyelocele
▪ Lateral defects (bilateral or unilateral) • Congenital connective tissue injury/weakness
◦ Rare cause of POP and stress urinary incontinence;
t
• Enterocele
ne
◦ Traction enterocele consider in young nulliparous women
▪ Occurs when posterior cul-de-sac is pulled • Chronically ↑ intraabdominal pressure
◦ Obstructed defecation, chronic respiratory
inferiorly by prolapsing cervix or vaginal cuff
e.
◦ Pulsion enterocele conditions
▪ Occurs when small intestine distends rectovaginal ◦ Occupational activities that result in repeated and
septum prolonged increases in intraabdominal pressure
yn
▪ Produces mass that may be hard to differentiate
Pathogenesis of POP
clinically from high rectocele •
bg Maintenance of normal pelvic floor tone is a complex
Vaginal Vault Prolapse (VVP) interaction between muscles and fascia
• Descent of vaginal apex or middle vaginal • Loss of muscle support to pelvic organs → increased
compartment tension on pelvic fascial support system
◦ Vaginal apex bulges into lumen or outside vagina ◦ Pelvic fascia is not built for prolonged tension,
ko
• Preexisting pelvic floor defect prior to hysterectomy is especially when muscle is also defective
single most important risk factor for vault prolapse ▪ Excessive tension → tears, separations, and
◦ Risk of vault prolapse following hysterectomy is 5.5x attenuation of fascia → failure of fascial support
oo
greater in women whose initial hysterectomy was for system → pelvic organ descent
genital prolapse as opposed to other reasons • Isolated support defects → fewer organs involved in POP
• Vaginal cuff prolapses include ◦ Little or no evidence of damage to pelvic diaphragm
eb
◦ Apical enterocele • Multiple support defects → several organs protruding

▪ Pubocervical and rectovaginal fascia are separated into vaginal canal
▪ Vaginal epithelium is stretched and becomes very ◦ Analysis of static and dynamic MR images allows
://
smooth without rugae determination of specific underlying defect(s)

▪ With stretching, peritoneum comes in direct ▪ Underlying defects may not be clinically evident
tp
contact with vaginal epithelium creating a true and only seen on MR

hernia ▪ Recognition and repair of all underlying defects
◦ Cystocele, rectocele improves surgical outcome and decreases rate of
ht
▪ Typically, some degree of high cystocele and high recurrence

rectocele
• Defects in cardinal and uterosacral ligaments CLINICAL EVALUATION
◦ Functionally, cardinal and uterosacral ligaments have
a complex integrated supportive role Symptoms Related to POP
▪ Originate over region of greater sciatic foramen • Defects of vaginal support are not uncommon and may
(cardinal) and lateral sacrum (uterosacral) be asymptomatic
▪ Insert to pericervical ring and upper 1/3 of vagina ◦ Pelvic system works as unit; defect in 1 component
at level of ischial spines may be compensated by other supporting structures

◦ Pull upper vagina posteriorly toward sacrum and thus • Vague symptoms described as feeling "something
suspend it over muscular levator plate coming down" or "feeling pressure in vagina"
▪ Detachment from pericervical ring results in VVP • Urinary symptoms
◦ Poor stream, hesitancy, straining, incomplete
and enterocele (apical prolapse)
emptying
◦ Stress urinary incontinence (SUI)
◦ Urgency and urge urinary incontinence (UUI)
▪ Many patients with POP have UUI due to detrusor
instability
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◦ Upper urinary tract symptoms • System identifies 9 points for measurement and
▪ Hydronephrosis uncommon but may be seen in up prolapse staging
to 8% of cases with severe prolapse ◦ Prolapse is staged by structure that protrudes most
• Sexual dysfunction during forceful straining
◦ Dyspareunia may occur either with vault prolapse or • Pelvic examination in POPQ
as postoperative complication ◦ Hymeneal ring of vagina is defined as reference point
• Anorectal ◦ Examination is performed in systematic fashion:
◦ Need to reduce bulge digitally to defecate &/or void Anteriorly, superiorly, posteriorly, and at external
introital surface
Clinical Findings Related to POP ▪ Structure that descends to level of hymeneal ring is
• Cystocele designated 0
◦ Mild to moderate cystoceles are usually
▪ Positive numbers are assigned to structures that
asymptomatic but can be associated with SUI protrude beyond hymeneal ring
◦ Difficult to clinically differentiate high-grade
◦ Characterizes level of defect, not what is on other side
cystocele from enterocele, VVP, or high rectocele ▪ Avoids use of specific labels such as cystocele,
◦ High-grade cystocele may mask SUI
rectocele, or enterocele
▪ Obstructed voiding associated with cystocele →
decrease of SUI symptoms TREATMENT
• Uterine prolapse
t
◦ Mild uterine prolapse is usually asymptomatic Conservative Management
ne
◦ Moderate to marked prolapse may cause • Includes pelvic floor exercise and pessaries (commonly,
▪ Vaginal mass &/or dyspareunia ring and shelf pessaries)
▪ Low back pain due to stretching of uterosacral ◦ Pessaries most often used for elderly patients for
e.
ligaments whom surgery is not an option
▪ Urinary retention and obstructive uropathy due to
urethral obstruction Surgical Management
yn
▪ Difficulty in defecating experienced by 1/3 of • Prolapse surgery aims at restoring normal vaginal
patients supports while maintaining vaginal capacity and coital
◦ Clinical grading of uterine prolapse may not correlate function
bg
• Surgical options for correction of vault prolapse include
with severity of symptoms
▪ Patients may have uterine descent sufficient to both vaginal and abdominal approach
• Vaginal approach
cause symptoms, but because they have a deep
◦ Vagina is anchored to existing stable structures such
ko
pelvis, extent of prolapse is not appreciable on

examination as sacrospinous ligament, iliococcygeus muscle, and
• Enterocele endopelvic fascia
oo
◦ Vaginal pressure, dragging sensation, dyspareunia • Abdominal approach

◦ Severe constipation &/or feeling of incomplete ◦ Vault suspension provides compensatory repair using
evacuation mesh
◦ Stretching of mesentery with straining can cause pain • Choice of approach is based on patient age,
eb
in lower abdomen or back comorbidities, previous surgery, and level of physical

◦ Clinical exam shows inferiorly displaced vaginal and sexual activity
vault and bulge in superoposterior vaginal wall
://
▪ Peristalsis of small bowel may be appreciated if RELATED REFERENCES

vaginal wall is thin
tp
1. Farouk El Sayed R: The urogynecological side of pelvic floor

▪ Clinical examination cannot reliably distinguish
MRI: the clinician's needs and the radiologist's role. Abdom
enterocele from rectocele Imaging. 38(5):912-29, 2013
▪ Missed enterocele can lead to recurrent prolapse
ht
2. Hale DS et al: Functional anatomy of the pelvic floor. In

after surgery Bartram C et al: Imaging Pelvic Floor Disorders. 1st ed.
◦ Vaginal overcrowding may lead to difficulty in Berlin, Heidelberg, New York: Springer. 27-38, 2003
diagnosis on physical examination 3. Hale DS et al: Urogenital dysfunction. In Bartram C et al:
▪ Accompanying organ prolapse can effectively mask Imaging Pelvic Floor Disorders. 1st ed. Berlin, Heidelberg,
New York: Springer. 107-24, 2003
presence of enterocele
4. Lienemann A et al: Functional imaging of the pelvic floor.
◦ Classification
Eur J Radiol. 47(2):117-22, 2003
▪ Simple enterocele: Cuff of vagina is well
5. Delancey JO et al: Size of the urogenital hiatus in the levator
supported with no VVP ani muscles in normal women and women with pelvic
▪ Complex enterocele: VVP with other forms of organ prolapse. Obstet Gynecol. 91(3):364-8, 1998
anterior or PVW prolapse 6. Gill EJ et al: Pathophysiology of pelvic organ prolapse.
• Rectocele Obstet Gynecol Clin North Am. 25(4):757-69, 1998
◦ Although result of PVW prolapse, it is usually 7. Theofrastous JP et al: The clinical evaluation of pelvic floor
dysfunction. Obstet Gynecol Clin North Am. 25(4):783-804,
discussed as pathological entity of posterior
1998
compartment 8. Bump RC et al: The standardization of terminology of
Pelvic Organ Prolapse Quantitation (POPQ) female pelvic organ prolapse and pelvic floor dysfunction.
•
Am J Obstet Gynecol. 175(1):10-7, 1996
Official grading system to standardize reporting and
8 classification
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Pelvic Floor
INTERACTION BETWEEN PELVIC FLOOR MUSCLES AND ENDOPELVIC FASCIA
Arcus tendineus fascia

pelvis
Urethra
t
Vagina
ne
Rectum
e.
Puborectalis muscle Iliococcygeus muscle
yn
Coccygeus muscle
bg
Piriformis muscle
ko
oo
Levator plate
eb
://
tp
ht
Graphic looking into the pelvis from above shows the upper layer of pelvic floor muscles and its interaction with the endopelvic fascial
condensations. The arrows indicate the direction of muscle forces. The anterior portion of the pubococcygeus muscle is attached to the lateral
vaginal wall and constitutes the forward force. The levator plate, attached to the posterior wall of rectum, constitutes the posterior force. The
net result of these opposing forces is a tightly closed urogenital hiatus. As a result, the endopelvic fascia is not exposed to any tension. Muscle
weakness or tear disrupts this balanced situation leading to pelvic organ prolapse (POP).
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VAGINAL FASCIAL SUPPORT SYSTEM
Level I: Uterosacral and

cardinal ligaments
Level II: Pubocervical fascia Uterine artery
Level II: Rectovaginal fascia
t
ne
Level III: Joining with
e.
perineal body
yn
bg
ko
oo
eb
://
tp
ht
Pubocervical fascia
(Top) Stylized oblique lateral view shows the levels of vaginal support. Level III of the posterior wall is located where the distal vagina abuts
the dense connective tissue of the perineal body. Note the dense fibrous tissue of the distal 2-3 cm of the pubocervical and retrovesical
fascia. Superior to this, there is less collagen and more smooth muscle and elastin. The uterine artery is the primary blood supply to the apical
fascia and ligaments. Note the straight posterior urinary bladder wall indicating intact pubocervical fascia. (Bottom) This graphic views the
supporting fascia and ligaments from above. The anterior wall vagina (V) is covered by the pubocervical fascia. The vagina is stretched like a
membrane between the following attachment points: Arcus tendineus fascia pelvis (ATFP) ligaments laterally and the anterior cervical ring and
its collagenous extensions onto the cardinal ligaments (CL) posteriorly.
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Pelvic Floor
UTEROCERVICAL FASCIAL SUPPORT
t
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e.
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bg
ko
oo
eb
://
Pubocervical fascia Rectovaginal fascia

tp
ht
Anterior vaginal wall Posterior vagina wall
(Top) Graphic shows the ligamentous support of the cervix. Cardinal ligaments (CL) are fibromuscular condensations of fascia that extend
from the upper end of the vagina to the lateral walls of the pelvis. Uterosacral ligaments (USL) consist of 2 firm fibromuscular bands of pelvic
fascia that extend from the cervix and upper end of the vagina to the lower end of the sacrum; they form 2 ridges, 1 on either side of the
rectouterine pouch of Douglas. The arrows indicate the line of tension created by ligaments to combat the force of gravity (F). (Middle) Graphic
representation of the posterior fornix of the vagina shows the role of the cervical ring in the interconnectedness of the pelvic fascia. A ring of
connective tissue, predominately composed of collagen, surrounds the cervix and acts as an anchoring point for the interconnecting fascial
sheets (PCF, ATFP, CL, USL, RVF = rectovaginal fascia). (Bottom) Graphic view simulating a sagittal plane shows the uterus acting like the
keystone of an arch. Hysterectomy alters this dynamic and can lead to POP.
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NORMAL VAGINAL FASCIAL SUPPORT
Arcus tendineus fascia pelvis Arcus tendineus fascia pelvis

(ATFP)
Levator ani Levator ani
t
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bg
ko
Normal posterior bladder

oo
wall
eb
Cervix
://
tp
ht
Normal bladder base
Vagina
(Top) Graphic shows the endopelvic fascia and spaces. The vagina is suspended between the 2 ATFP ligaments by lateral fascial extensions.
These lateral extensions fuse with the pubocervical fascia superiorly and the rectovaginal fascia inferiorly. Pelvic organs are separated from
each other by spaces that allow organs to move independently from each other. (PVS = paravesical space, VVS = vesicovaginal space, RVS =
rectovaginal space, RRS = retrorectal space, PRS = pararectal space or ischiorectal fossa.) (Bottom) Axial T2WI MR composite shows normal
level I and level II endopelvic fasciae. The landmark to define level I is the cervix (upper image), and level II is the mid vagina at the level of the
bladder base (lower image). While some ligaments are visualized, the fascia is not; however, the integrity of the fascia can be inferred by the
appearance of surrounding organs. The posterior bladder wall is seen as a straight line, indicating that the level I and level II endopelvic fascia is
intact.
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FASCIAL DEFECTS
Bladder Uterus
Level of high cystocele (level I)
Cervical ring
Level of mid cystocele (level II)
Pubocervical fascia
Rectovaginal fascia
Vagina
t
ne
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Uterus
yn
bg
Cervical ring
ko
Pubocervical fascia
oo
ATFP
eb
://
tp
ATFP attachment to ischial spines

Normal location of ATFP
ht
Detached ATFP
(Top) Graphic shows the interaction between the intact endopelvic fascia and the pelvic organs. The pubocervical fascia extends as a broad
membrane between the bladder neck and the cervical ring. The bladder base sits on this membrane. Collagen and smooth muscle within the
vaginal wall provide its main structural components. The circles indicate sites of high and mid cystoceles. (Middle) Graphic shows the underlying
pathogenies of a high cystocele. The ring around the cervix is composed of collagen and provides a strong anchoring point for the fibromuscular
fascia, which extends forward below the bladder. Tearing of the fascia at the site of attachment may present as high cystocele, high rectocele,
or enterocele. (Bottom) Diagram shows the pathogenesis of a paravaginal defect. It is helpful to conceptualize the ATFP as 2 suspended lines
extending between the symphysis pubis and ischial spines. Dislocation of the ATFP from the lateral vaginal wall causes a "dip" through which
bladder sagging occurs. This may occur either unilaterally or bilaterally, the latter often being asymmetric.
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PARAVAGINAL FASCIAL DEFECT
t
ne
e.
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bg
ko
oo
eb
://
Left paravaginal fascial

tp
defect
ht
Right paravaginal fascial

defect
(Top) In this graphic, there is right-sided endopelvic fascial detachment causing a paravaginal defect. Because of the defective support
mechanism, there is sagging of the right posterolateral wall of the urinary bladder to fill the resulting defect. (Bottom) Axial T2WI MR obtained
in a woman with POP shows the consequences of ATFP detachment with sagging of the posterior vaginal wall (saddlebag sign). It is asymmetric
with a large defect on the right and small defect on the left. The degree of sagging of the bladder wall corresponds to the size of the fascial
defect. This may help determine the appropriate surgical approach; surgical repair of fascia, if the defect is small vs. use of mesh, if the defect is
large.
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CENTRAL FASCIAL DEFECT
Intact ATFP
Stretched and redundant PCF
t
ne
e.
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bg
ko
oo
eb
://
Central bulge of posterior bladder wall

tp
Vagina
ht
(Top) Graphic shows the central type of fascial defect. In a central defect, the lateral attachment of the fascia to the ATFP is intact with stretching
and redundancy of the central pubocervical fascia. (Middle) Graphic shows a central vertical defect. This results from damage to the middle
of the pubocervical fascia, allowing the central portion of the bladder wall to bulge posteriorly (distension cystocele). (Bottom) Axial T2WI MR
obtained in a woman with POP shows bulging of the central part of the posterior urinary bladder wall. Because a central defect is not due to
fascial tear but rather fascial stretching, the bladder wall bulging is usually small compared to paravaginal defects.
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ETIOLOGY OF POP
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(Top) The muscular support system with its associated fascial support is the most important contributor to the integrity of the pelvic floor, with
the perineal body and superficial muscle being of far less importance. (Bottom) A wide variety of conditions may contribute to the disruption of
these support structures, ultimately leading to pelvic organ prolapse.
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Pelvic Floor
DEFECT-SPECIFIC POP
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POP is a complex, multifactorial process with interdependent muscular and fascial defects. The fascia provides anchoring points and stabilization
for the musculature, which is the primary support for the pelvic floor. Muscular defects, irrespective of type, will eventually result in a fascial
defect as fascia does not have the strength to withstand intraabdominal pressures over a prolonged period of time. The type of prolapse will
relate to the specific area of damaged fascia.
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Pelvic Floor MIDDLE COMPARTMENT IMAGING
Key Facts
MR: Modality of Choice ◦ Normally dome-shaped appearance at rest with
• Technique upward convexity
◦ Patient preparation, positioning, and dynamic/static ◦ With straining, muscle becomes horizontal with
MR imaging should follow same protocol used for basin-shaped configuration
anterior compartment ◦ Also evaluate for thinning and discontinuity of
◦ Requires repeated straining phases in sagittal plane muscle fibers
◦ Monitoring of straining effort is critical to ensure • "Pelvic competition" occurs in high-grade POP
adequate straining ◦ Descent of 1 organ may mask other organ prolapse
◦ MR defecography is mandatory for evaluation of POP, • Levels I and II paravaginal fascial defects result from
especially in recurrent cases detachment of lateral vaginal support → triangular
defects adjacent to vagina
Image Interpretation ◦ Fascial defect itself is not seen but is inferred by
• Levels of endopelvic fascia evaluated sagging posterior wall of urinary bladder, a.k.a.
◦ Level I: Located at level of cervix saddlebags sign
◦ Level II: Located at level of trigone or bladder base • Levels I and II central fascial defect results from fascial
• Normally attached lateral vaginal support results in redundancy without actual detachment
straight posterior wall of urinary bladder ◦ Inferred by sagging of central part of urinary bladder
t
• Iliococcygeus muscle posterior wall
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(Left) Axial T2WI MR obtained
in a volunteer with no PFD
shows the normal level
I endopelvic fascia. The
bg
landmark to define this level
is the cervix . The posterior
bladder wall has a straight
ko
contour. The status of an intact
fascia is inferred on the MR
by the normal appearance of
the related organ. (Right) Axial
oo
T2WI MR obtained in the same

volunteer shows normal level
II endopelvic fascia, which
eb
supports the bladder. The

landmark for this level is the
bladder base. The posterior
bladder wall has a straight
://
contour.
tp
ht

woman with POP shows a
sagging posterolateral bladder
wall (saddlebags sign)
indicating bilateral level I
paravaginal defects. The
defects are asymmetric and
larger on the right side. (Right)
Axial T2WI MR obtained
in the same patient at level
II endopelvic fascia (level
of the bladder base) shows
bilateral, almost symmetric
paravaginal defects . The
defects are smaller than at
level I. Fascial defects are of
various locations, severity,
and may occur in various
8 combinations.
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MIDDLE COMPARTMENT IMAGING
Pelvic Floor
MR ▪ With straining, muscle becomes horizontal with
basin-shaped configuration
Technique ◦ Iliococcygeus angle (ILCA): Angle between
• Patient preparation, positioning, and dynamic/static iliococcygeus muscle and transverse plane of pelvis
MR imaging should follow same protocol used for ▪ 33.4° ± 8.2 SD during straining in women with
anterior compartment intact pelvic floor
Dynamic MR Classifying Vaginal Support System Defects

• The following maneuvers are essential components • Levels I and II paravaginal fascial defects result from
of dynamic imaging in higher grades of pelvic organ detachment of lateral vaginal support → triangular
prolapse (POP) defects adjacent to vagina
◦ Requires repeated straining phases in sagittal plane ◦ Best evaluated on axial T2WI
◦ Monitoring of straining effort to ensure adequate ▪ Fascial defect itself is not seen but is inferred by
straining is crucial sagging posterior wall of urinary bladder, a.k.a.
◦ These precautions are recommended to exclude saddlebags sign
hidden enterocele or other masked POP – Bladder creeps to fill in resulting defect
• "Pelvic competition" occurs in high-grade POP ◦ Defects of various sizes occur; size of defect depends
◦ Descent of 1 organ may mask or lower grade of on level of fascial detachment
another organ's prolapse ▪ Moderately wide defect corresponds to midlevel
t
• In all grades of POP, especially recurrent cases, MR vaginal detachment
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defecography is mandatory ▪ Large defect corresponds to upper levels of vaginal
◦ Evacuation phase is highly recommended to be part of detachment
routine dynamic imaging protocol ▪ In severe cases of uterine prolapse, cervix might
e.
be visualized at lower level than its normal resting
Static MR position
• Imaging planes • Levels I and II central fascial defect results from
yn
◦ Axial plane fascial redundancy without actual detachment
▪ Main sequence in which endopelvic fascia is ◦ Best evaluated on axial T2WI
evaluated ▪ Inferred by sagging of central part of posterior
▪ Sections must cover cranially up to uterine cervix
bg
urinary bladder wall
◦ Coronal plane ▪ Central defect is usually small
▪ Main plane to evaluate iliococcygeus muscle • Iliococcygeus muscle
◦ Sagittal plane
ko
◦ Best evaluated in coronal plane

▪ Can also be used to evaluate iliococcygeus muscle ◦ Iliococcygeus muscle is evaluated for diffuse or focal
– Muscle is best evaluated in parasagittal sections muscle abnormality
oo
◦ Diffuse muscle abnormality may be in form of

▪ Symmetrical loss of normal muscle bulk on both
IMAGE INTERPRETATION sides
▪ Unilateral or asymmetric diffuse thinning
eb
Normal Vaginal Support System

• Endopelvic fascia ◦ Focal muscle abnormality includes
◦ Levels of endopelvic fascia ▪ Focal thinning
▪ Level I is located and evaluated at level of cervix – Unilateral or bilateral
://
(level of bladder apex or fundus) – Bilateral symmetric or asymmetric

– Supports bladder and contributes to uterine ▪ Focal defect
tp
support – Focal discontinuity of muscle fibers (may occur

▪ Level II is located and evaluated at level of trigone at site of muscle attachment or within muscle
ht
or bladder base substance)

– Supports bladder (important part of pubocervical – Bowel herniation may occur through muscle
fascia) defect (may lead to obstructed defecation)
◦ Appearance of normally attached lateral vaginal Cystocele and Enterocele
support • Dynamic MR defecography is mandatory in such cases
▪ Evaluated on axial T1WI and T2WI • Repeated straining by patient and monitoring by
– Straight posterior wall of urinary bladder radiologist is important to ensure adequate straining
– Cervix is seen at same or slightly higher level • Conventional cystocolpoproctography can diagnose
– Vagina: Level I is straight or curved, level II enterocele provided that opacification of small bowel is
becomes H-shaped included
▪ Intact supporting fascia is not directly visualized
but inferred by normal bladder and vaginal Masked Stress Urinary Incontinence (SUI)
contours • POP may compress urethra, masking symptoms of SUI
• Iliococcygeus muscle • Thorough assessment of urethral supporting system on
◦ Evaluated on coronal T1WI and T2WI static MR images is essential
▪ Normally dome-shaped appearance at rest with ◦ Detection of injury of any urethral supporting
upward convexity structures confirms presence of masked SUI
▪ No asymmetry between muscle plates on either side 8
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• Failure to recognize masked SUI preoperatively may ▪ Organs are individually opacified
result in development of SUI postoperatively • Prolapse of pelvic organs, including bladder base,
◦ 2nd operation may be needed to address SUI VVP, enterocele, and sigmoidocele, is also defined
• Anti-incontinence procedures, if done with initial radiologically by reference to PCL
cystocele repair, result in clinical improvement • Grading of POP
◦ Prolapse of any of these organs is graded according to
Grading of Uterine Prolapse and Cystocele "rule of 3"
• Rule of 3: Prolapse below pubococcygeal line (PCL) ◦ Rectocele
◦ Mild :≤ 3 cm ▪ Anterior rectocele is defined as anterior rectal wall
◦ Moderate: Between 3 and 6 cm bulge
◦ Severe: ≥ 6 cm ▪ Lateral and posterior rectocele may also occur
• Dynamic MR is modality of choice for prolapse grading • Time consuming and exposes patient to significant
• Static MR is modality of choice for identifying amount of ionizing radiation
underlying pelvic supporting system defect ◦ May fail to detect enterocele in 20% of patients
• Diagnosis and grading of uterine prolapse is crucial
prior to repairing cystocele or incontinence surgery
Vaginal Vault Prolapse (VVP) PERINEAL ULTRASOUND IN POP
• Patient preparation, positioning, dynamic/static MR Technique
t
imaging should follow same protocol used for anterior • Dynamic transperineal ultrasound
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compartment ◦ Probe is placed on perineum
◦ Vaginal opacification with sterile lubricating gel ◦ Scanning is performed in sagittal and coronal planes
to enhance visualization is strongly advised, if not
◦ Movement of pelvic floor is observed during straining
mandatory
e.
and squeezing
◦ In addition to PCL, which is used routinely in MR,
▪ During straining, cystocele, enteroceles, and
another reference line, midpubic line (MPL), can be
rectocele may become apparent
yn
used
• Has considerable potential as a simple, cheap, and
▪ MPL is drawn along long axis of pubic bone on noninvasive technique; however, relationship to
sagittal image
other imaging methods and reliability await further
– Corresponds to level of vaginal hymen, the
bg
assessment
landmark for clinical staging
▪ Reported to improve accuracy in VVP diagnosis
▪ Simplified scoring system is used to facilitate
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TREATMENT
description on MR of vaginal compartment
involved Surgery
– A = anterior compartment (equivalent to high • Dynamic and static MR findings are critical in choice of
oo
cystocele) operative approach

– M = middle compartment (vaginal apex or vault) ◦ Vaginal approach
– P = posterior compartment (equivalent to high ▪ Considered appropriate for patient with good pelvic
eb
rectocele &/or enterocele) floor muscle strength as depicted on dynamic MR

◦ Stages of prolapse ▪ Reasonably substantive endopelvic fascia assessed
▪ Different stages of prolapse are described as ranging on static MR images
://
from 0-3 as referenced by distance from MPL ◦ Abdominal approach in women with 1 of the
– Stage 0: No descent following
– Stage 1: < 2 cm descent ▪ Poor pelvic floor muscle strength
tp
– Stage 2: > 2 cm and < 4 cm ▪ Attenuated fascia

– Stage 3: > 4 cm ▪ Repeat repair or severe ongoing physical stress
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Conservative Therapy
DYNAMIC CONTRAST • Physiotherapy is appropriate if there is only muscle
weakness
CYSTOCOLPOPROCTOGRAPHY (CCOP)
Indication of Examination
• Patient with contraindications to MR imaging
SELECTED REFERENCES
• Patient with complex pelvic organ prolapse who failed 1. García Del Salto L et al: MR imaging-based assessment of the
to strain and evacuate injected ultrasound gel on MR female pelvic floor. Radiographics. 34(5):1417-39, 2014
table 2. Woodfield CA et al: Imaging pelvic floor disorders:
trend toward comprehensive MRI. AJR Am J Roentgenol.
Technique 194(6):1640-9, 2010
• Requires opacification of the following pelvic organs 3. El Sayed RF et al: Pelvic floor dysfunction: assessment with
◦ Bladder, vagina, small bowel, and rectum
findings. Radiology. 248(2):518-30, 2008
• 2 imaging techniques
◦ 1 phase
▪ All organs are opacified at same time
8 ◦ Multiple phases
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Pelvic Floor
woman with POP at the level of
the cervix shows bilateral level I
paravaginal defect. The defects
are asymmetric, moderate
on the left side and small on the
right. (Right) Axial T2WI MR in
the same patient at the level of
the bladder base shows a straight
bladder , indicating intact
level II endopelvic fascia. Patients
may have variable types and
severity of defects at different
fascial levels.
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woman with POP shows level I
paravaginal defects. There are
bg bilateral asymmetric defects ,
which are large on the right side
and small on the left side. Also
note the normally straight border
ko
of the vagina is now convex

with the lateral margins sagging
posteriorly . (Right) Axial
oo

with POP at the level of bladder
base shows almost straight
posterior urinary bladder wall
eb
and vagina , indicating intact

level II endopelvic fascia.
://
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(Left) Sagittal BFFE MR in a

woman status post hysterectomy
demonstrates the importance of
vaginal opacification. Without
gel, the vagina cannot be
appropriately evaluated. (Right)
Visualization is greatly improved
with vaginal opacification .
The midpubic line (MPL) is
shown, which corresponds to the
level of the vaginal hymen. The
distal vagina extends below
this line. The MPL is an adjunct
to the PCL and is particularly
useful in vaginal vault prolapse as
demonstrated in this case.
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(Left) Coronal BFFE MR of

a volunteer woman with no
PFD at rest shows normal
iliococcygeus angle (ILCA)
measuring 22.4° . The angle is
plotted between the transverse
plane of the pelvis and a line
parallel to the iliococcygeus
muscle sling. (Right) Coronal
BFFE MR in the same volunteer
woman with no PFD at
maximum straining shows
mild vertical descent of the
iliococcygeus muscle with
slight increase in the ILCA
angle.
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(Left) Coronal BFFE MR in a
woman with no POP at rest
shows normal slope of the
iliococcygeus muscles with a
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normal ILCA measuring 23° .
(Right) Coronal BFFE MR of
the same patient with PFD
ko
at maximum straining shows

moderate vertical descent of
the iliococcygeus muscle with
oo
an increase in the ILCA angle

to 42.6° .
eb
://
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(Left) Coronal BFFE MR in a

woman with no POP at rest
shows normal slope of the
iliococcygeus muscles with
a normal ILCA measuring
23° . (Right) Coronal BFFE
MR of the same patient with
PFD at maximum straining
shows advanced elongation
and vertical descent of the
iliococcygeus muscle with an
increase in the ILCA angle to
72° . The muscle may appear
normal at rest and only shows
abnormal descent during the
dynamic portion of the exam.
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Pelvic Floor
(Left) Dynamic coronal BFFE MR
at rest in a patient complaining
of POP shows bilateral diffuse
and symmetric thinning of the
iliococcygeus muscles .
(Right) Dynamic coronal BFFE
MR in the same patient during
bilateral marked diffuse and
symmetric thinning and descent
of the iliococcygeus muscles .
This case is an example of diffuse
muscle abnormality.
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(Left) Dynamic parasagittal
BFFE MR at rest in a patient
complaining of PFD shows
bg diffuse thinning of the ventral
part of the iliococcygeus muscle
with a focal area of apparent
discontinuity . (Right)
ko
Dynamic parasagittal BFFE

maximum straining confirms
oo
the presence of diffuse focal

bulge of the iliococcygeus
muscle without discontinuity
of the muscle fibers. This case
eb
demonstrates an example of focal

muscle abnormality in the form
of thinning.
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(Left) Dynamic coronal BFFE MR

at rest in a patient complaining
of POP shows bilateral diffuse
and symmetric thinning of the
iliococcygeus muscles ,
more advanced on the right
side. (Right) Dynamic coronal
BFFE MR in the same patient
during maximum straining shows
bilateral diffuse thinning of the
iliococcygeus muscles with
detachment of the right
iliococcygeus muscle creating
a large defect. This case is an
example of focal muscle defect.
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(Left) Dynamic coronal

BFFE MR at rest in a patient
complaining of vaginal
pressure with obstructed
defection shows preserved
muscle bulk of both
iliococcygeus muscles .
(Right) Dynamic coronal
BFFE MR during maximum
straining in the same patient
shows thinning of the right
iliococcygeus muscle and
herniation of the rectum
through a muscular defect.
This case demonstrates focal
muscle defect, accompanied
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by bowel herniation.
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(Left) Dynamic coronal BFFE
MR during moderate straining
in a woman complaining of
lower back pain and episodes
bg
of obstructed defecation shows
a right iliococcygeus muscle
defect with herniation of
ko
ultrasound gel-filled rectum

through the muscular defect.
(Right) Dynamic coronal
oo

during maximum straining
shows further herniation of
the rectum through the
eb
iliococcygeus muscle defect.

://
tp
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(Left) Sagittal BFFE MR

obtained during moderate
straining shows a grade II
cystocele and uterine descent
and a peritoneocele .
There is relatively widened
and ill definition of the anal
canal. (Right) Sagittal BFFE
MR in a patient with ascites
and complete procidentia
shows that the urinary bladder
is totally inverted with
the urethra at a higher
level than the urethrovesical
junction . There is also
complete uterine prolapse.
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Pelvic Floor
(Left) Sagittal BFFE MR during
rest in a woman complaining of
vaginal mass shows apparently
normal appearance of the
iliococcygeus muscle. (Right)
Sagittal BFFE MR in the same
patient during maximal straining
shows a focal bulge in
the region of thinning of the
iliococcygeus muscle.
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(Left) Dynamic axial BFFE
MR in the same patient at rest
shows normal appearance of
bg the puborectalis muscle .
(Right) Dynamic axial BFFE
ko
obvious ballooning of the

puborectalis muscles as
well as a focal bulge and focal
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thinning of the left muscle due to

uterine descent.
eb
://
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(Left) Dynamic coronal BFFE

MR at rest in the same patient
shows preserved muscle bulk
of both iliococcygeus muscles
. (Right) Dynamic coronal
during moderate straining shows
thinning of the left iliococcygeus
muscle . The muscle is
deformed and stretched over the
sagging uterus .
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Pelvic Floor OVERVIEW OF THE POSTERIOR COMPARTMENT
ANATOMY OF ANAL Puborectalis

• Constant tone causes anterior displacement of anal
SPHINCTER COMPLEX (ASCX) canal, resulting in acute anorectal angle
Description • Acute angulation resists fecal outflow and is essential in
• Envelops anal canal maintaining rectal continence
• • Under physiologic conditions, this angle can be altered
Tilted anteriorly in sagittal plane, with cranial part
anterior either to augment continence or to assist defecation
• ◦ To facilitate defecation, puborectalis is relaxed and
Composed of several cylindrical layers
◦ Smooth muscle layer of internal sphincter brief Valsalva maneuver augments pelvic floor
◦ Intersphincteric space containing longitudinal descent
◦ To defer defecation, puborectalis contracts, causing
smooth muscle layer
◦ Outermost striated external anal sphincter (EAS) rectum to become more perpendicular to anal canal,
which elevates pelvic floor and lengthens anal canal
Internal Anal Sphincter (IAS)
• Composed of smooth muscle fibers PHYSIOLOGY OF ANORECTAL REGION
◦ Continuation of circular layer of rectal muscularis
propria, which increases in thickness below anorectal Factors Contributing to Anal Continence
junction to form circular internal sphincter • Normal defecation and maintenance of continence is a
• sophisticated process requiring
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Ends ~ 1 cm above inferior margin of ASCx
◦ Inferior part of ASCx is composed solely of external ◦ Rectal filling
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sphincter ◦ Awareness of rectal filling
• 2-3 mm thick on endoluminal imaging ◦ Ability to propel stool and relax pelvic floor muscles
◦ Progressive ↑ in thickness with advancing age in coordinated fashion
e.
• Maintains anal sphincter resting tone (contributes up • An intact ASCx exerts background of constant pressure
to 85% of maximal anal resting pressure) with intermittent increases to maintain mucosal seal
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despite wide fluctuations of rectal pressure
Intersphincteric Space and Longitudinal ◦ Tension of anal sphincter muscles is most important
Smooth Muscle Layer factor in maintaining anal continence
▪ Maximal anal resting pressure is ~ 40-80 mm Hg
• Intersphincteric space is a thin, fat-containing space
bg
with variable thickness ◦ Sphincter function is impaired if there is a defect in
◦ Located between IAS and outer striated muscles sphincter muscular ring
• Several factors act in concert to maintain fecal
ko
(external sphincter and puborectalis)
◦ Hard to discern in some individuals, though easily continence
visible in others ◦ Anatomical factors including anal sphincter, pelvic
• floor muscles, and acute anorectal angle
oo
Intersphincteric space contains longitudinal smooth

muscle layer, a continuation of the longitudinal layer of ◦ Passive barriers include transverse rectal folds, lateral
rectal muscularis propria angulation of sigmoid colon, valve of Houston, and
◦ Receive striated muscle contributions from anal cushions
eb
puborectalis muscle and fibroelastic element from Rectoanal Inhibitory Reflex (RAIR)
endopelvic fascia •
◦ Upper part is predominantly muscular while lower
Rectal distension from stool or gas induces reflex
relaxation of IAS, known as RAIR
://
part is predominantly fibroelastic ◦ Amplitude and duration of this relaxation increases

◦ ~ 2.5 mm thick; thickness ↓ with age
with volume of rectal distention
tp
External Anal Sphincter (EAS)

• Cylindrical striated muscle layer under voluntary CLINICAL EVALUATION
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control ANORECTAL DYSFUNCTION

• Predominantly composed of slow-twitch muscle fibers,
capable of prolonged contraction Fecal Incontinence
• Forms outer and inferior portion of anal sphincter • Fecal incontinence may be described as
• ~ 2.7 cm in height (shorter anteriorly in women, ~ 1.5 ◦ Passive: Passage of stool without patient awareness
cm) (mostly due to IAS damage)
• Some anterior fibers decussate into superficial ◦ Urge: Passage of stool despite attempts to inhibit
transverse perineal muscle and perineal body defecation (mostly due to EAS damage)
• Nerve supply ◦ Nocturnal incontinence: Suggests neurological cause
◦ Inferior rectal branch of pudendal nerve (S2, S3) and • Fecal incontinence can be
perineal branch of S4 ◦ Minor: Just staining of underwear or bedding
• Function ◦ Major: Definite soiling considered by patient to be a
◦ Contributes 15-20% of resting anal tone problem
◦ Voluntary control of sphincter complex • Parks grading system is commonly used to quantify
▪ Major role in continence control, such as during ↑ fecal incontinence
intraabdominal pressure or to defer defecation ◦ Grade 1 is continent
◦ Grade 2 is incontinent for flatus
◦ Grade 3 is incontinent for liquid stool
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OVERVIEW OF THE POSTERIOR COMPARTMENT
Pelvic Floor
◦ Grade 4 is incontinent for solid stool • Patient ingests a gelatin capsule containing 24 precut
• Wexner questionnaire is a widely used scoring system radiopaque polyvinyl chloride markers (each of which
◦ Combines estimation of leakage frequency, need to is 4.5 mm x 1 mm)
wear a pad, and overall effect on lifestyle • On day 5, abdominal radiograph is obtained
• Interpretation of study is based on number and
Constipation and Obstructed Defecation distribution of retained markers
• Slow colonic transit ◦ Subjects with normal colonic motility expel > 80% of
◦ Infrequent defecation and small, hard stool imply
markers
slow transit colonic time ◦ Patients who retain ≥ 5 radiopaque markers have
• Prolonged or incomplete defecation
positive study
◦ Excessive straining, need for pelvic support or digital
▪ Retained markers scattered throughout colon
manipulation suggests pelvic floor dysfunction
suggest colonic inertia
Clinical Examination for Assessment of Anal ▪ Accumulation of markers in rectosigmoid suggests
Sphincter and Pelvic Floor functional outlet obstruction

• Abdominal examination
◦ Abdominal distention and colonic fecal loading in
DYNAMIC AND STATIC PHASED-ARRAY MR
severely constipated patients Technique
• Perineal and anal sphincter examination • Patient preparation, positioning, and imaging protocol
t
◦ Women with disruption of EAS may have gross
are same as in other compartments
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abnormalities of perineal body • Dynamic evacuation MR sequence is mandatory to
◦ Anal sphincter tone is assessed by performing
assess anorectal dysfunction
rectovaginal examination while patient contracts ◦ Provides information about pelvic floor weakness
e.
pelvic floor musculature ◦ For patients with obstructed defecation, it is advised
◦ Thickness of rectovaginal septum is assessed during
to increase amount of injected gel to 180-200 mL
rectovaginal examination
yn
(from the usual volume of 120 mL)
◦ Perineal descent results from chronic straining with • Static MR provides detailed information about anal
defecation sphincter
▪ Characterized by perineal descent below bony
bg
Imaging Planes and Field of View
pelvis during straining
• Examination of levator ani muscle tone • Axial and coronal images are obtained perpendicular
◦ Examiner palpates muscle with 2 gloved fingers in and parallel to plane of anal canal, respectively
ko
posterior vagina, 2-4 cm above hymeneal ring • Axial oblique plane shows full extent of external
◦ Patient is asked to squeeze pelvic muscles slowly sphincter and its relation to perineal body
◦ Assess whether patient can contract muscles, as well ◦ Also delineates fibers of superficial transverse perineal
oo
as strength and duration of contraction muscle as it enters perineal body and ischioanal fossa
• Examination of posterior vaginal compartment • Coronal oblique plane demonstrates relationship
◦ Laceration of posterior vaginal fourchette due to between levator ani and rectum
• Sagittal plane provides information on anterior and
eb
childbirth is most common defect

◦ Rectal prolapse is defined as protrusion of mucosa posterior relationships of anal canal
and rectal muscular tube beyond anal canal • Complete anal sphincter evaluation requires imaging of
◦ Full extent of superficial and deep EAS
://
ANORECTAL PHYSIOLOGY TESTS ◦ Puborectalis muscle

◦ Perineal muscle, perineal body, and iliococcygeus
IN ANORECTAL DYSFUNCTION
tp
muscle
Anorectal Manometry MR Appearance of ASCx
• Anal sphincter function is assessed by measurement of
ht
• ASCx is depicted as a cylindrical structure extending

◦ Resting sphincter pressure, which predominantly
from the insertion of levator ani muscle into rectum, to
reflects IAS function external anal margin
◦ Squeeze sphincter pressure, which reflects EAS
• On T2WI, 4 layers can be clearly visualized
function ◦ Mucosa
◦ Functional length of anal canal
▪ Thin folded inner layer of high signal intensity
Electromyography (EMG) ▪ Histologically, corresponds to mucosa as well as
• Examines presence or absence of relaxation failure of intraluminal mucous secretions
▪ Consistently seen above level of dentate line but
puborectalis musculature
not below this level (due to lack of mucus-secreting
Pudendal Nerve Terminal Motor Latency epithelium below level of the dentate line)
(PNTML) Test ◦ Submucosa
• Evaluates nerve control of external sphincter muscles ▪ Layer of low signal intensity
▪ Smooth external contour, but folded internal
Motor-Evoked Potentials contour
• Evaluates integrity of entire spino-anorectal pathways ▪ Low signal is due to presence of dense collagen,
Sitzmarks Transit Study elastic fibers, and submucosal smooth muscle

• Evaluation for constipation/delayed colonic transit called the musculus submucosa ani
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◦ IAS ▪ Caudal ends of EAS fold inward and upward,

▪ Homogeneous isointense to hyperintense (relative forming a double layer
to striated muscle) circular band with smooth ▪ Length of inner layer of EAS is 5-11 mm in women
contours surrounding anal canal ▪ Separated from IAS by intersphincteric space
▪ Distal aspect of IAS ends superior to distal part of ▪ EAS has been described as consisting of 1, 2, or 3
external sphincter parts
◦ EAS and longitudinal muscle layer ▪ For simplicity, subcutaneous and superficial
▪ Low signal intensity components are considered 1 muscle: SEAS
▪ Somewhat heterogeneous due to presence of fat ◦ Levator ani
▪ Fatty plane is present between longitudinal ▪ Puborectalis overlaps EAS for a distance of 2-5 mm
muscle and EAS, more prominent at distal part of in midcoronal plane
longitudinal muscle ▪ Levator ani anchors sphincter complex to internal
• Contrast-enhanced MR images portion of pelvis and forms ceiling of ischiorectal
◦ Anal cushions fossa
▪ Anal canal is filled with strongly enhancing ◦ Coronal images from anterior to posterior show
structures, corresponding to hemorrhoidal vascular ▪ Anteriorly, puborectalis is located inferolateral to
tissue (anal cushions) that provide complete iliococcygeus muscle
sealing of anal canal ▪ More posteriorly, puborectalis muscle appears
▪ Abnormalities of anal cushions may influence triangular and is attached to urogenital diaphragm
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▪ At level of anal canal, puborectalis muscle is
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treatment of incontinence in some patients
▪ Anal cushions are not seen with endoluminal oblong, and there is a cleft between EAS and
imaging techniques puborectalis muscle
◦ IAS shows strong enhancement on post-contrast ▪ Posteriorly, EAS consists of 1 muscle layer, and
e.
T1WI levator ani muscle gradually becomes horizontal in
position
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• Sagittal plane (midline sagittal section)
• Axial plane ◦ Dorsal aspect of anal canal has 2 characteristic muscle
◦ Lowermost part of external sphincter is superficial
masses, forming a double bump
external anal sphincter (SEAS) ▪ Caudal muscle mass represents a combination of
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▪ Appears as 2 parallel band-like structures, 1 on each
superficial and deep parts of EAS
side of IAS, directed anteroposteriorly ▪ Dorsal and cranial muscle mass corresponds to
▪ More cranially, the 2 muscles gradually merge and
puborectalis sling
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form a complete circle around anal canal ◦ Anteroposterior relations

◦ Middle 1/3 of external sphincter (deep EAS)
▪ Caudal fibers from outer layer of EAS extend
▪ Sphincter thickens to form most prominent part of
anteriorly to fuse with bulbocavernosus
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sphincter complex ▪ Posteriorly, EAS is anchored to coccyx by

▪ Has a characteristic teardrop shape
anococcygeal ligament
▪ Axial images at this level demonstrate intimate
Dimensions of ASCx
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relation between perineal body and EAS

◦ Upper 1/3 of external sphincter (deep EAS) • Measurements of ASCx
▪ Inner fibers of EAS appear as a complete circle ◦ Measurements of sphincter dimensions differ
surrounding IAS between different imaging modalities
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▪ Outer fibers are attached to surrounding muscles ▪ Radiologist needs to refer to normal sphincter
and septa of ischioanal fossa values specific to each technique to determine
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▪ Puborectalis muscle appears as a U-shaped sling whether measured thickness is normal or abnormal
around upper part of anal canal in ribbon-like ▪ Imaging technique should be standardized to
fashion minimize effect of technical variables
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• Identifying components of ASCx on sequential • Impact of age and parity

axial images ◦ IAS becomes progressively thicker with advancing age
◦ Superficial part of external sphincter is present ▪ Muscle thickness increases by 0.13 mm every 10
▪ Below level of transversus perinei superficialis years as measured on endoanal MR
muscle ▪ Most likely result of connective tissue infiltration
◦ Deep part of external sphincter rather than true hypertrophy
▪ Thick, and encircles anal canal ◦ Parity has little effect on anal sphincter dimensions
◦ Puborectalis muscle • Sexual differences of ASCx and perianal structures
▪ Seen just superior (cephalad) to the 2 sphincters ◦ IAS and longitudinal muscle are thinner in men than
◦ Perirectal fascia in women
▪ Superior to level of levator ani ◦ EAS is thicker in men than in women
▪ Seen as a thin stripe of low signal intensity on both ◦ Anterior portion of EAS is shorter and thicker in
T1WI and T2WI women than in men
• Coronal plane ▪ Length: ~ 11 mm in women and ~ 14 mm in men
◦ EAS ▪ Thickness (measured in mid sagittal plane): 3.5 mm
▪ Outermost hypointense layer surrounding lower in women and 3 mm in men
◦ Puborectalis muscle is more curved in women and
8 part of anal canal
more straight in men
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◦ Often a thin fat plane is seen between DEAS distally
ENDOANAL MR and puborectalis muscle proximally
Indication ◦ EAS has characteristic "j" shape
• High intrinsic contrast resolution results in accurate
delineation of sphincter complex CONVENTIONAL EVACUATION
Technique PROCTOGRAPHY ("DEFECOGRAPHY")
• Patient preparation Indications
◦ No bowel preparation; patient fasts for 4 hours prior • Fecal incontinence, obstructed defection, and pelvic
to examination to reduce bowel motion artifact pain
◦ Patient empties bladder before study to prevent
discomfort from distended bladder and consequent Technique
• Patient preparation
motion artifact
◦ Important to instruct patient not to contract pelvic ◦ Cleansing rectal enema day before examination
◦ Patient ingests a barium meal 1.5 hours before
floor muscle
◦ Smooth muscle relaxant butylscopolamine examination
◦ Thick barium paste with a consistency similar to fecal
(Buscopan) 20 mg/mL to reduce peristalsis and
associated motion artifact material is administered into rectum (injected with a
• Coils pistol injector)
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◦ Dedicated endoanal coils are preferred over rectal ◦ Vagina is opacified with contrast
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• Imaging protocol
coils
▪ Design of rectal coils makes them less suitable for ◦ Ensure patient understands and can follow
endoanal imaging instructions
e.
▪ Some rectal coils for prostate imaging are sensitive ◦ Patient is seated on a commode placed on footrest
in 1 plane only of upright-positioned examination table in front of

▪ Range of coil diameter is 17-19 mm fluoroscopic unit
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◦ Device is covered with a commercial probe cover or ▪ Left lateral views of pelvis are taken during
condom, and lubricant is applied on surface fluoroscopy

▪ Amount of lubricant should be minimized to ▪ Frontal view may occasionally be obtained
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◦ Spot films are obtained at
reduce high signal intensity caused by near field
▪ Rest or neutral position
effect
◦ Endoanal coil is introduced with patient in left lateral ▪ Squeezing: Voluntary and maximal contraction of
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decubitus position sphincter and pelvic floor muscles

◦ Patient is turned supine, and coil is secured in ▪ Straining without defecating
▪ During defecation (evacuation of injected barium
position
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• Sequences and protocol paste)

◦ T2WI sequences are most useful ◦ Cine imaging of rectal evacuation with large FOV
◦ An example of protocol that can be used on 1.5 T ▪ To ensure capturing anal canal in cases of marked
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magnet includes the following T2W turbo spin-echo ano-rectal junction descent
◦ Whole procedure takes 10-15 minutes
(SE) parameters
▪ TR/TE: 2800, 90 ms • Tips to ensure adequate imaging
▪ Field of view (FOV): 120 x 90 mm ◦ Tip of coccyx must be included in FOV
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▪ imaging matrix: 512 x 256 ◦ Soft tissue shadow of buttocks should also be
▪ slice thickness: 2-3 mm included to facilitate visualization of anal verge
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▪ NSA: 8
Image Analysis
◦ Contrast resolution is evaluated by checking
• Structures evaluated during defecography include
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difference in signal intensity between IAS ◦ Anorectal junction (ARJ) descent

(hyperintense) and EAS (relatively hypointense) ▪ Pelvic floor descent on defecation is estimated
• Imaging planes by degree of descent of ARJ in relation to inferior
◦ Axial plane is orientated perpendicular to anal canal
margin of ischial tuberosity or pubococcygeal line
axis (PCL)
◦ Should be supplemented by at least 1 longitudinal
◦ Anorectal angle (ARA)
plane, coronal preferred over sagittal ▪ Represents activity of puborectalis muscle
▪ Coronal plane reduces partial volume effect and
▪ Measured from axis of anal canal to a line either
provides additional information on extent of along posterior wall or through central axis of
disorder rectum
◦ Phase-encoding direction should be adjusted to
◦ Anal canal length (ACL)
prevent artifacts in anterior part of anal sphincter ▪ Defined as distance between external anal orifice
Normal Appearance of Anal Sphincter and ARJ
• ◦ Rectosacral gap
Axial plane
◦ Anal sphincter is recognized by its 4 layers and their ▪ In resting state, width of gap between posterior
different signal intensities as seen on phased-array rectal wall and sacrum at S3 level is measured
directly
•
MR images
Coronal plane ▪ Usually < 1 cm
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◦ Subepithelium: Innermost thin hypoechoic crescents

Findings in Normal Subjects
• At rest of muscularis submucosa ani visible in upper canal
◦ Vascular channels
◦ Anal canal is closed and puborectalis impression
▪ May be seen at 6 and 12 o'clock as anechoic tubular
clearly defined
◦ ARJ is at or just above PCL structures running longitudinally
▪ Anal cushions are compressed by probe and usually
◦ ARA ranges from 60-120°
▪ Average is ~ 90° not visible unless hemorrhoidal
◦ IAS
◦ ACL is 10-20 mm
▪ Presents as a well-defined ring of uniform low
◦ Rectosacral gap: No focal thickening of rectosacral
space echogenicity ~ 2 mm thick
◦ EAS
• On squeezing
▪ Surrounding ring of mixed echogenicity striated
◦ Anal canal is closed
◦ ARJ is ~ 5 mm above PCL muscle
◦ ARA usually decreases to ~ 75° Limitations
◦ ACL increases • Tissue layers are thin, and acoustic impedance
◦ Elevation of posterior rectal wall with closure of differences are often minimal
anal canal as a result of increased contraction of • MR provides more accurate measurement of muscle
puborectalis sling and levator ani thickness
t
▪ "Squeeze" film is therefore a relatively reliable test
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of pelvic floor function
• During straining RELATED REFERENCES
◦ Anal canal is closed 1. El Sayed RF et al: Pelvic floor dysfunction: assessment with
◦ ARJ descends < 3.5 cm from resting position
e.
▪ Average ARJ descent: 2-3 cm (not > 4.5 cm) findings. Radiology. 248(2):518-30, 2008
◦ ARA increases by 10-30° from resting 2. Bartram CI: Fecal incontinence. In Bartram CI et al: Imaging
yn
Pelvic Floor Disorders. Berlin, New York: Springer, 2003
▪ Average: 100-120°
3. Beets-Tan RG et al: Measurement of anal sphincter muscles:
◦ ACL decreases
endoanal US, endoanal MR imaging, or phased-array MR
• Normal evacuation imaging? A study with healthy volunteers. Radiology.
bg
◦ Anal canal should open widely 220(1):81-9, 2001
▪ Mean AP diameter: 1.5 cm 4. Beets-Tan RG et al: High-resolution magnetic resonance
◦ ARJ descent ≤ 3 cm from PCL imaging of the anorectal region without an endocoil.
ko
◦ ARA increases due to descent and relaxation of pelvic Abdom Imaging. 24(6):576-81; discussion 582-4, 1999
5. Benson JT: Female pelvic floor disorders: Investigation and
floor muscles management. New York: W. W. Norton, 1992
▪ As a result, distal rectum and upper anal canal
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assume continuous funnel-shaped configuration

◦ ACL decreases
◦ Rectal emptying is extremely variable
▪ Complete emptying in only 1/2 of normal
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population
◦ Rectocele
▪ Common finding (in ~ 80% of asymptomatic
://
women)
▪ Generally small, < 2 cm in depth
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▪ Rarely retains barium at end of evacuation
Limitations
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• Time consuming; uses significant levels of ionizing

radiation
• Unable to visualize components of anal sphincter
• Wide overlap in standard defecographic measurements
ENDOANAL SONOGRAPHY
Technique
• Ultrasound gel is used inside and outside of probe cover
to ensure good acoustic contact
• Patient is positioned in lithotomy position (preferred)
or prone
• Series of images should be taken on withdrawal of probe
to record appearances of canal at all levels, with detailed
scanning of any abnormality
Normal Anatomy and Diagnostic Criteria
•
8 ASCx appears as 4-layered structure
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ANATOMY OF RECTUM AND ANAL CANAL
Intraperitoneal rectum
Extraperitoneal rectum
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e.
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From T10-L2
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Hypogastric nerve
Inferior mesenteric ganglion
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Pelvic nerves
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(parasympathetic)
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Bladder (smooth muscle) Pudendal nerve (somatic)
External sphincter (striated Pelvic floor (striated muscle)

muscle)
(Top) Graphic shows the anatomy and subdivisions of the rectum. The intraperitoneal rectum is related anteriorly to the upper vagina and uterus.
The extraperitoneal rectum is related anteriorly to the posterior vaginal wall and rectovaginal septum. The inferior rectum has no mesentery but is
enveloped in fat and is bordered by the mesorectal fascia (mesorectum). The anal sphincter envelops the anal canal and is composed of several
cylindrical layers. (Bottom) Graphic shows innervation of the anal sphincter. The external anal sphincter (EAS) receives its sensory and motor
supply from inferior rectal nerve, the 1st branch of the pudendal nerve. Inferior rectal nerve may arise directly from 3rd-4th sacral spinal nerves
and communicates with the perineal branch of the posterior femoral cutaneous and the posterior labial nerves. Pain from external hemorrhoids is
perceived by these fibers. The internal anal sphincter (IAS) receives visceral sensory innervation that travels with parasympathetic nerves.
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ANATOMY OF RECTUM AND ANAL CANAL
Rectum proper
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Puborectalis muscle
Anal sphincter muscle
Anal canal, titled anteriorly complex
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Uterus
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Rectum
Urinary bladder
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Tip of coccyx
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Urethra
Puborectalis muscle
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Anal canal
Perineal body
(Top) The rectum is formed from the terminal portion of the colon. It begins at the level of the 3rd segment of the sacrum and ends at the anus.
Anatomically, it is divided into 2 sections: The rectum proper (10-12 cm in length), and the anal canal (3-4 cm in length). The ampullary portion
of the rectum rests on the pelvic diaphragm; at this level, it turns ~ 90° posteriorly. The anal sphincter is tilted anteriorly in the sagittal plane. The
cranial part of the EAS has a close anatomical relationship with the puborectalis. The anal canal is fixed posteriorly to the sacrum by the presacral
fascia (fascia of Waldeyer). The rectovaginal fascia gives anterior support to the rectum in women. (Bottom) Sagittal T2WI shows the relations of
the anal canal. Anteriorly, the anal canal is related to the perineal body, the lower part of the vagina, and the anovaginal septum. The attachment
to the perineal body is important for anal canal support. Posterior support is provided by the anococcygeal ligament.
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ANAL SPHINCTER COMPLEX
Longitudinal muscle layer

of muscularis propria of the
rectum
Circular muscle layer of

muscularis propria of
Iliococcygeus muscle rectum
Anal cushion
Puborectalis
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muscle complex
Superficial external anal
sphincter
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ko
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Puborectalis muscle
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Deep external anal
sphincter

sphincter
(Top) The IAS is a continuation of the circular muscle layer of the muscularis propria of the rectum. The longitudinal muscle layer is located
within the intersphincteric fat and is a continuation of the longitudinal muscle layer of the muscularis propria of the rectum. The EAS is
composed of multiple components and constitutes the outer and inferior part of the anal sphincter complex. The lowermost part of the anal
canal is surrounded by the superficial external anal sphincter (SEAS). At a higher level, the anal canal is surrounded by the IAS, longitudinal
muscle layer, and the EAS. The uppermost part is surrounded by the IAS, longitudinal muscle layer, and puborectalis muscle. (Bottom) Coronal
T2WI shows the sphincter complex. The EAS envelops the intersphincteric space. The IAS extends from the anorectal junction to ~ 1 cm below
the dentate line. The lower muscular part of the anal sphincter is made only of the external sphincter, levator ani, and the transverse perineal
muscles.
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MR APPEARANCE OF ANAL SPHINCTER COMPLEX
Rectum
Puborectalis
Deep external anal

sphincter
Coccyx
Perineal body
Anococcygeal body
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sphincter Anal canal
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Subcutaneous external anal
sphincter
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Anus
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bg
ko
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://

tp
sphincter
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(Top) Graphic shows the arrangement of the puborectalis muscle and the external anal sphincter (EAS). The EAS has been described as
consisting of subcutaneous, superficial, and deep parts. For simplicity on MR imaging, the subcutaneous and superficial parts are considered 1
muscle, termed the superficial external anal sphincter (SEAS). The puborectalis muscle is responsible for the creation of the anorectal angulation.
(Bottom) Axial oblique BFFE MR image shows the SEAS. It is the lowermost part of the external sphincter and appears as 2 parallel muscles
directed anteriorly to posteriorly.
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Mucosa
Submucosa Internal anal sphincter
External anal sphincter Longitudinal muscle layer
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e.
Mucosa
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Submucosa Internal anal sphincter
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Intersphincteric space containing
longitudinal smooth muscle layers
Deep external anal sphincter
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Mucosa
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Submucosa
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(Top) The anal sphincter complex shows 4 layers of different signal intensity. The mucosa is the thin folded inner layer of high signal intensity.
The submucosa is of low signal intensity and has a folded internal contour and smooth outer contour. The internal anal sphincter appears as
a homogeneous isointense to hyperintense (relative to the striated muscle) smooth circular band surrounding the anal canal. The longitudinal
smooth muscle layer and the fatty component of the intersphincteric space are more prominent at the distal part of the deep external anal
sphincter (DEAS). (Middle) Axial oblique BFFE MR image of the anal sphincter complex shows the DEAS. The middle 1/3 of the DEAS forms
the most prominent part of the sphincter and has a characteristic teardrop shape around the IAS. (Bottom) Axial oblique BFFE MR image shows
the anal sphincter complex at the upper 1/3 of the DEAS. The innermost fibers of the EAS are completely circular. The deep part of the external
sphincter is thick and encircles the anal canal.
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Lower 1/3 of deep external

anal sphincter
sphincter
Middle 1/3 of deep external

anal sphincter
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Overlap between lower and
e.
middle 1/3 of deep external
anal sphincter
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bg
ko
Full teardrop appearance of Internal anal sphincter

middle 1/3 of deep external
anal sphincter
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Middle 1/3 of deep external

Longitudinal muscle layer anal sphincter
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://
tp
Puborectalis muscle
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Upper 1/3 of deep external

anal sphincter
(Top) Cranial to the level of the superficial EAS (which can be distinguished by its unique MR configuration) is the DEAS. The DEAS is further
subdivided into the lower 1/3, which is the first 3 to 4 sections, below the level of the transversus perinei superficialis muscle, the superficial part
of the external sphincter is present, just cranial to the SEAS, middle 1/3, and upper 1/3. (Bottom) The middle 1/3 of the DEAS can be identified
by the teardrop appearance of the sphincter. The puborectalis muscle is seen just cephalad to the IAS and EAS and does not extend along the
ventral portion of the rectal wall. The puborectalis forms a sling along the posterior anorectum.
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Pelvic Floor
Urethra Iliococcygeus muscle
Ischioanal space
Puborectalis muscle
Iliococcygeus muscles
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Ischioanal space
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Deep external anal
sphincter
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ko
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Deep external anal

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sphincter Superficial external anal

sphincter
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Cleft between puborectalis

Deep external anal
muscle and deep external
sphincter
anal sphincter
(Top) Sequential coronal T2W images of a female volunteer show the details of the sphincter complex from anterior to posterior. The upper 2
sections are anterior to the anal canal. The puborectalis muscle is inferolateral to the iliococcygeus muscle. Both muscles run perpendicular to
the urogenital diaphragm. Note the anterior extension of the ischioanal space. More posteriorly, the DEAS is visible as a separate muscle. Note
the funnel-shaped iliococcygeus muscle and the ischioanal space. (Bottom) Sequential coronal T2W images of a female volunteer show the anal
sphincter complex. The upper 2 images are at the anal canal proper. The lower part of the anal canal is surrounded by the IAS and the EAS,
while its upper part is surrounded by the IAS and puborectalis muscle. The lower 2 images are more posterior and show the cleft between the
EAS and the puborectalis muscle. The direction of the fibers differ between the EAS and puborectalis muscle. The iliococcygeus muscle has a
more horizontal orientation.
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CONVENTIONAL EVACUATION PROCTOGRAPHY (DEFECOGRAPHY)
Tip of coccyx
Contrast within vagina
Puborectalis impression
Ischium Anorectal angle
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e.
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bg Tip of coccyx
Contrast in vagina
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Anorectal angle
Ischium
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://
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Tip of coccyx
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Contrast in vagina
Ischium
Anorectal angle
Anal canal
(Top) Conventional defecogram obtained during rest shows a closed anal canal and a well-defined puborectalis impression posteriorly. The
anorectal junction (ARJ) is just above the level of the ischium. The anorectal angle (ARA) is ~ 115° (normal range is 60-120° ) and no soft
tissue mass is present in the sacroanal space. (Middle) Conventional defecogram obtained during squeezing shows a closed anal canal and a
well-defined puborectalis impression posteriorly. The ARJ is elevated in relation to the ischium when compared to the rest position. The ARA
decreased to ~ 90° . (Bottom) Conventional defecogram obtained during evacuation shows a widely open anal canal, measuring ~ 17 mm. The
ARJ descends to about the level of the ischium. The ARA markedly widens due to descent and relaxation of the pelvic floor muscles.
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RECTUM/ANAL CANAL: ANATOMICAL RELATIONS AND SUBDIVISIONS
Transverse perineal muscle
Submucosa
Longitudinal muscle
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Submucosa

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Longitudinal muscle

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Puborectalis muscle
Fat of ischiorectal fossa

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Subcutaneous part of external anal

sphincter
(Top) The 1st of 3 transanal endosonography images taken in a male at high, middle, and low levels is shown. The IAS appears as a thin black
ring encircling the submucosa, and it is continuous with the muscularis propria of the rectum. Likewise, the outer longitudinal muscle is an
extension of the muscularis propria in the rectum conjoined with fibers from the levator ani. (From IA: Ultrasound.) (Middle) The EAS is less well-
defined and more echogenic and, in males, forms a complete ring. (From IA: Ultrasound.) (Bottom) At the lower level, the subcutaneous part of
the EAS is visible on ultrasound. (From IA: Ultrasound.)
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Pelvic Floor IMAGING OF FECAL INCONTINENCE
TERMINOLOGY Idiopathic
• Usually associated with patulous anal sphincter and
Definitions passive stretching of puborectalis muscle
• Although the term anal incontinence is more
appropriate to use as it describes involuntary loss of
Traumatic Rupture
• Straddle injury may result in simple or extensive
flatus, liquid, or solid stool; fecal incontinence is the
synonymous term more commonly used in clinical laceration of perineum
practice Congenital Anorectal Anomalies
◦ Prevalence of some degree of fecal incontinence in • High anomalies requiring pull-through procedures
general population is ~ 2%, rising to 7% in elderly result in much greater anatomical derangement with
increased risk of sphincter damage
ETIOLOGY OF FECAL INCONTINENCE • Low lesions often involve a membrane covering anal
Obstetrical Trauma canal with intact sphincteric mechanism
• Most common cause of fecal incontinence in healthy Other Abnormalities of Gastrointestinal
women Tract
• Most common cause of external anal sphincter (EAS) • Rectal prolapse
injury ◦ Fecal incontinence is common in patients with rectal
◦ Internal anal sphincter (IAS) tears do not occur
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prolapse, affecting ~ 50% of patients
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without EAS damage ◦ IAS is invariably weakened as a result of prolapse; EAS
◦ Extent of IAS disruption usually matches that of EAS
•
is variably affected
Vaginal delivery can damage fecal continence ◦ Incontinence occurs due to pelvic floor neuropathy
mechanism by
e.
◦ Direct injury to sphincter muscles → early onset fecal
produced by rectal prolapse
▪ May also be secondary to loss of EAS tone from
incontinence
constant dilation by prolapsing tissue
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▪ Develops immediately post partum
• Enterocele
▪ 13% of women suffer from incontinence or
• Descending perineal syndrome
urgency following their 1st vaginal delivery ◦ May be secondary to prolonged straining → damage
▪ Sphincter injury suffered during 1st delivery may
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to pudendal nerves by stretching
be insufficient to compromise continence •
◦ Damage to motor innervation of pelvic floor → late-
Rectovaginal fistulas
◦ Inflammatory bowel disease (most commonly in
onset fecal incontinence
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▪ Develops several years after childbirth

patients with Crohn disease)
◦ Malignant tumors, due to tumor invasion or
▪ Results from stretching of nerve due to dilation of
radiation treatment
introitus by fetal head
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▪ Nerve damage is likely cumulative

IMAGING FINDINGS IN
Surgical Procedures Damaging Anal FECAL INCONTINENCE
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Sphincter
• Lateral internal sphincterotomy
Defecographic Findings
• Mild to moderate fecal incontinence
◦ Previously common procedure for anal fissuring prior
◦ Leakage at rest implies weakness of IAS
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to pharmacological treatments
◦ Failure to narrow patulous anal canal upon squeezing
▪ Now, performed mainly for chronic unresponsive
suggests loss of EAS function
cases
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◦ Inability to reduce anorectal angle (ARA) on

◦ Procedural goal is to divide only lower 1/3 of IAS,
squeezing implicates puborectalis sling defect
allowing cut ends to separate and leave a small gap
• Severe fecal incontinence
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◦ If entire internal sphincter is cut, weakness of IAS

◦ Anal canal is abnormally widened at rest
occurs and can lead to fecal incontinence
◦ Rectum frequently has vertical configuration
• Other surgical procedures that may damage the
◦ Gross pelvic floor descent is usually present
sphincter include
◦ Rectovaginal fistula repair, colpoperineorrhaphy, Anal Sphincter Defects and Scar Tissue
hemorrhoidectomy, and therapeutic anal dilation • Defects of anal sphincter may affect EAS or IAS
• Traditionally, site of defect is described by referring to
Neurological Damage
• "anal clock"
Pudendal nerve damage (supplies anal sphincter and
◦ Based on view of anal sphincter complex with patient
pelvic floor)
◦ Childbirth, diabetes mellitus, and low anterior in lithotomy position
▪ 12 o'clock is anterior perineum
resection are most common causes of pudendal nerve
▪ 6 o'clock is natal cleft
injury
▪ 3 o'clock is left lateral aspect of anal canal
• Damage of autonomic supply of rectum
▪ 9 o'clock is right lateral aspect of anal canal
◦ Diabetes mellitus and low anterior resection may be
• Lesions of anal sphincter muscles can be
associated with profound autonomic neuropathy,
◦ Frank defects (tears)
leading to dysfunction of colorectum and IAS
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IMAGING OF FECAL INCONTINENCE
Pelvic Floor
▪ Defect of EAS or IAS appears as discontinuity of • Distal part of EAS may appear to have posterior defect
muscular ring, often with scarring &/or fraying of ◦ Normal variant
borders ◦ Muscle fibers run along both sides of anococcygeal
▪ Tears may be partial or complete ligament, producing "defect"
▪ Tear locations should be described according to ◦ On higher images, posterior EAS fibers are seen to
"anal clock" and longitudinal extent reported merge symmetrically, reestablishing sphincteric ring
▪ At endoanal US, defects in IAS appear as • True defects are asymmetric, irregular, and bordered
hyperechoic gaps in normally hypoechoic ring; with scar tissue, distinguishing them from pitfalls
defects in EAS appear as relatively hypoechoic areas
in normally hyperechoic ring CHOICE OF IMAGING TECHNIQUE
◦ Functional defects due to scar tissue
▪ On MR, scar tissue appears as a hypointense Phased-Array vs. Endoanal MR
• Advantages of phased-array MR
deformation on sphincter complex
▪ On endoanal sonography, scar tissue appears as ◦ Simpler examination
◦ Imaging of whole pelvic floor supporting system in
hypoechoic focus, disrupting normal pattern of
muscle layer single comprehensive examination
▪ Scar tissue distorts normal multilayered • Advantages of endoanal MR
◦ Assessment of fine details of sphincter muscle and
architecture of sphincter muscle and is often
continuous with scar tissue adjacent to sphincter more accurate measurement of muscle thickness
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▪ May be focal or diffuse • Both techniques are comparable in depicting clinically
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▪ Scar tissue is more hypointense compared to relevant anal sphincter defects and depiction of
striated muscle on MR sphincter atrophy
• ◦ Provided that sufficient experience in assessing
Anal sphincter defects can be distinguished from
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scarring, though there is no clinical significance phased-array images is available
between them Endoanal MR vs. Endoanal US
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• EAS continuity should be confirmed by evaluating • Endoanal MR and endoanal US are comparable for
for fusion of anterior segments at midline, forming depicting EAS defects
complete ring ◦ Either technique can be considered effective when
◦ If EAS is eccentric, it is suggestive of tear
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▪ May be confirmed on coronal imaging
◦ Local expertise is important when choosing endoanal
Atrophy of Anal Sphincter imaging
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• • IAS tears are best evaluated with endoanal US
EAS atrophy
◦ Characterized by thinning of muscle fibers &/or • MR is superior in detecting EAS atrophy
replacement of muscle fibers by fat (may be atrophied
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without significant thinning) RELATED REFERENCES

▪ Relatively common condition in patients with fecal
incontinence of anatomic and functional abnormalities. Radiographics.
▪ Histologically, striated muscles exhibit diminished
eb
34(2):429-48, 2014
volume in association with replacement by fatty 2. García Del Salto L et al: MR imaging-based assessment of the
tissue female pelvic floor. Radiographics. 34(5):1417-39, 2014
▪ Anal sphincter is better seen on endoanal MR due 3. Malouf AJ et al: Prospective assessment of accuracy of
://
to high spatial resolution endoanal MR imaging and endosonography in patients with

◦ Normal thickness of EAS is 4 mm fecal incontinence. AJR Am J Roentgenol. 175(3):741-5,
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▪ Thickness < 2 mm indicates EAS atrophy 2000

▪ Endoanal MR allows measurement of EAS thickness
and accurate assessment of its fat content
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• IAS atrophy or primary degeneration of IAS

◦ Generalized thinning of IAS to thickness < 2 mm in
middle-aged or elderly women
▪ IAS should become thicker with age
▪ Normal thickness of IAS is 2.7 mm
▪ More accurately measured by endoanal MR
• Although atrophy is visible in all planes, coronal plane
gives best estimation of overall sphincteric volume and
allows for comparison of both sides
• Difficult to recognize on endosonography
Important Pitfalls
• At transition from deep EAS to puborectalis, separation
of muscle groups is not clear
◦ Muscle fibers intermix, with some inserting into
perineal body and others continuing anteriorly
◦ May result in gap that may be misdiagnosed as
anterior defect 8
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NORMAL ANATOMY AND EVACUATION MECHANISMS
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Pubic symphysis
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Puborectalis External anal sphincter
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(Top) Graphic shows the normal anatomy and physiology of the pelvic floor at rest. If defecation is inconvenient, the sensation of the need to
defecate prompts voluntary contraction of the external anal sphincter (EAS). As the rectum relaxes and the sensation of the need to defecate
dissipates, more stool can be accommodated. (Bottom) As stool distends the rectum, there is reflex relaxation of the internal anal sphincter (IAS)
and the perception of the need to defecate. Sensory mechanisms in the anal canal enable determination of whether rectal content is gas or stool.
When defecation is socially appropriate, the anal sphincters and the puborectalis relax. An increase in abdominal pressure and rectal contraction
generates a force to expel stool from the rectum. Thus, sensory perception and physiological coordination are integral components of anorectal
function.
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CONTINENCE MECHANISMS AND ETIOLOGIES OF INCONTINENCE
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Flow chart summarizes the diversity of factors that control the continence mechanism and the etiology of fecal incontinence.
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ANAL SPHINCTER ABNORMALITIES
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Chart illustrates the most common etiological factors leading to damage confined to the anal sphincter complex and resulting in fecal
incontinence.
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ABNORMALITIES OF IAS AND EAS ON MR
Left fibrotic SEAS

Right SEAS of normal intermediate
signal intensity
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Scarred dorsal aspect of IAS

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IAS
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Focal thinning of EAS

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Thinned DEAS
(Top) Axial oblique BFFE MR image in a patient presenting with fecal incontinence shows hypointense deformation of the left superficial external
anal sphincter (SEAS) due to fibrosis and scarring. The left SEAS is irregular and more hypointense compared to the right SEAS. (Middle) Axial
oblique BFFE MR image in a patient presenting with fecal incontinence shows thinning and low signal intensity of the posterior aspect of the
internal anal sphincter (IAS), indicating fibrosis and scarring. (Bottom) Axial oblique BFFE MR image in the same patient also shows a focal area
of advanced thinning of the deep external anal sphincter (DEAS) on the right side from the 7- to 9-o'clock positions.
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Internal anal sphincter (IAS)
Defect of DEAS at 9 o'clock Defect of DEAS at 3 o'clock
Low signal intensity of muscle

posteriorly
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Relatively normal left DEAS
Extensive scarring of right IAS and deep
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external anal sphincter (DEAS)
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Extensive fibrosis along ventral aspect

of IAS, EAS, and perineum
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Normal external anal sphincter (EAS)
(Top) Axial oblique BFFE MR image in a patient presenting with fecal incontinence shows discontinuity of the external anal sphincter (EAS)
muscle ring. A muscle defect should be described according to clock face; this is an anterior defect extending from 9 to 3 o'clock. Additionally,
there is abnormal low signal intensity of the deep external anal sphincter (DEAS), suggestive of muscle scarring. (Middle) Axial oblique BFFE MR
image in a female patient presenting with fecal incontinence shows a complex deformity involving both the DEAS and internal anal sphincter
(IAS). There is extensive scarring involving the right side of the anal sphincter complex from the 6- to 10-o'clock positions. (Bottom) Axial oblique
BFFE MR image in a female patient presenting with fecal incontinence shows extensive scarring involving the IAS, EAS, and perineum, extending
from 11 to 1 o'clock.
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Remnants of external anal sphincter

(EAS) muscle
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Mucosa extending through IAS defect
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Right margin of IAS defect at 10 o'clock Left margin of IAS defect at 12 o'clock
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Left torn edge of deep external anal
Right torn edge of DEAS at 9 o'clock sphincter (DEAS) tear at 3 o'clock
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Scarring of perineal body

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(Top) Axial oblique BFFE MR image in a female patient presenting with fecal incontinence shows almost complete loss of volume of the external
anal sphincter (EAS) muscle with a normal appearance of the internal anal sphincter (IAS). Fragmented remnants of the EAS muscle are present
in the 12- to 3-o'clock positions. (Middle) Axial oblique BFFE MR image in a patient presenting with fecal incontinence shows multiple sites
and types of anal sphincter abnormalities. There is an anterior defect of the EAS extending from the 9- to 3-o'clock positions.The IAS shows
diffuse distortion of the normal homogeneous appearance, as well as an anterior defect extending from the 10- to 12-o'clock positions. There is
bulging of the high signal intensity mucosa through the defect. (Bottom) Axial oblique BFFE MR image in a female patient presenting with fecal
incontinence shows extensive scarring of the IAS and EAS from the 11- to 5-o'clock positions with scarring of the perineal body.
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FECAL INCONTINENCE ON CONVENTIONAL DEFECOGRAPHY
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Open anal canal
(Top) Conventional defecography image at rest in a patient with mild fecal incontinence shows an open anal canal with barium leakage,
indicating weakness of the IAS. (Bottom) Conventional defecography image in the same patient during squeezing shows failure of the anal canal
to narrow, suggesting loss of EAS function. Inability to reduce the anorectal angle on squeezing implicates the puborectalis sling mechanism.
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FECAL INCONTINENCE ON CONVENTIONAL DEFECOGRAPHY, SPHINCTER ABNORMALITIES ON US
Anterior rectocele
Anal canal opened at rest
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Intact anterior internal anal sphincter
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(IAS)
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Focal thinning of posterior IAS
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IAS
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Focal scarring
(Top) Conventional defecography in a patient with severe fecal incontinence at rest shows a patulous anal canal. The rectum has a relatively
vertical configuration. A wide ARA indicates gross pelvic floor descent. Overall, evacuation proctography is of limited value in incontinent
patients unless they have associated obstructive symptoms. Evacuation proctography cannot add information about sphincter strength beyond
that already obtained from manometry. (Middle) Transverse endoanal ultrasound image shows a hyperechoic gap in the normally hypoechoic
ring of the IAS at the 5- to 8-o'clock position. (Bottom) Transverse endoanal ultrasound image in the same patient at the level of the mid anal
canal shows an inverted V-shaped hypoechoic defect of the external anal sphincter (EAS) at the 6-o'clock position. At endoanal US, defects
in the IAS appear as hyperechoic gaps in the normally hypoechoic ring, while defects in the EAS appear as hypoechoic clefts in the normally
hyperechoic ring.
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Pelvic Floor IMAGING OF OBSTRUCTED DEFECATION
TERMINOLOGY ABNORMALITIES OF RECTAL EVACUATION

Abbreviations Rectocele
• Obstructed defecation (OBD) • Anterior rectocele is abnormal bulging of anterior wall
of rectum into posterior vaginal wall
PATHOPHYSIOLOGY OF CONSTIPATION • Common in women; small rectoceles may be
considered normal variant
General Considerations ◦ Reported in 96% of asymptomatic women
• Constipation describes symptom, not clinical sign • Strong association between large rectocele and difficult
◦ Particularly subjective, meaning different things to
rectal evacuation
different people • Etiology
• There is considerable individual variation in defining ◦ Traumatic, due to damage of rectovaginal fascia
constipation during childbirth
◦ Some patients will concentrate on bowel frequency ◦ Chronic straining at stool, most likely due to
◦ Others will be more concerned about ease of
functional disorder of evacuation
defecation and stool size/consistency • Physical examination can detect majority of rectoceles
• Satisfactory definition of constipation must include ◦ However, it does not provide accurate assessment of
both infrequent defecation and difficult evacuation size or ability to empty during defecation
◦ Infrequent defecation
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▪ Usually defined as < 3 bowel movements per week Descending Perineum Syndrome (Pelvic
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▪ Most likely associated with slow transit time Floor Descent)
◦ Difficult evacuation • Posterior compartment pelvic floor abnormality
▪ Straining at stool is considered to be abnormal if it
defined as descent of anorectal junction > 3 cm below
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occurs for > 25% of time spent in lavatory pubococcygeal line (PCL)
▪ Indicates obstructed defecation ◦ Usually generalized process with associated
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• Chronic constipation abnormal descent of middle and anterior pelvic floor
◦ Very common
compartments
◦ Estimated that 1 in 5 healthy, middle-aged adults ◦ Often seen in combination with perineal ballooning,
have symptoms suggesting functional constipation
bg rectocele, intussusception, and impaired evacuation
• Recognized underlying causes include
2 Major Types of Constipation
◦ Pudendal nerve impairment (due to childbirth
• Slow transit type (infrequent evacuation)
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◦ Movement of fecal material through colon is slow trauma or neuropathy)
◦ Chronic straining → pudendal nerve stretching
◦ Majority of patients have no readily identifiable
• Initially present with constipation and perineal pain,
organic cause
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◦ Classified on basis of functional disturbance but over time fecal and urinary incontinence dominate
▪ Assessed by anorectal physiology testing, transit clinical symptomology
◦ Secondary to sphincter denervation and subsequent
studies, and evacuation proctography
◦ Slow colonic transit time and abnormal rectal incontinence
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evacuation frequently coexist Intussusception and Rectal Prolapse

▪ Slow transit may be normal physiological response • Rectal prolapse is full-thickness extrusion of rectal wall
to obstructed evacuation
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beyond anal verge

◦ Patients who solely exhibit slow colonic transit time ◦ Intussusception (internal rectal prolapse) is full-
are likely to be suffering from idiopathic slow transit thickness prolapse of rectum that does not protrude
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constipation through anus

▪ Almost exclusively young women ▪ Intrarectal intussusceptions are confined to rectal
▪ Suffer constitutional symptoms and abdominal
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ampulla (mild degree may be seen in normal

bloating with dramatically reduced stool frequency subjects)
▪ Many patients exhibit abnormal antroduodenal ▪ Intraanal intussusception extends into anal canal
manometry, indicating generalized gastrointestinal • Often coexist with rectocele &/or enterocoele
motility abnormality • Usually originate 6-8 cm above anal canal at level of
▪ Underlying disorder remains obscure (possibly
main rectal folds
representing generalized sensory and autonomic • May involve all rectal wall layers or confined to mucosa
neuropathy) and subjacent layers
• Outlet obstruction or obstructed defecation ◦ Since intussusception is circumferential process,
◦ Patients have trouble evacuating rectal contents and
isolated involvement of anterior rectal wall should be
must strain forcefully and for prolonged periods more accurately termed "anterior rectal wall mucosal
◦ Experience feelings of incomplete evacuation after
prolapse"
stool passage • Intussusception occurs only when rectum collapses
◦ Assessment of rectal evacuation is probably single
during evacuation
most important test in severely constipated patient • Mechanism of intussusception and rectal prolapse
remains poorly understood
◦ Patients share several anatomic features
8 ▪ Abnormally deep pelvic cul-de-sac
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IMAGING OF OBSTRUCTED DEFECATION
Pelvic Floor
▪ Redundant rectosigmoid colon • Anterior rectocele is quantified by depth of protrusion
▪ Lax and atonic pelvic floor musculature, including beyond expected margin of normal anterior anorectal
anal sphincter wall on sagittal images at conventional evacuation
▪ Lack of normal sacral fixation of rectum proctography and MR defecography
• As intussusception progresses, supporting structures ◦ Small: < 2 cm
of rectum and pudendal nerves are stretched → pelvic ◦ Moderate: 2-4 cm
floor neuropathy → progressive weakening of levator ◦ Large: > 4 cm
ani and anal sphincter → progressive worsening of • Defecography provides information about size and
rectal prolapse dynamics of rectocele emptying, retention of contrast
• In adults, rectal prolapse is seen much more frequently medium within rectocele, and coexistent abnormalities
in women ◦ Can also differentiate between the 2 main types of
• Symptoms include bleeding, mucous discharge, rectocele according to underlying etiology
obstructive defecation, and rectal pain ▪ Trauma: Suggested by sharply angulated contours,
◦ Patients may need vaginal, perineal, or rectal especially if associated with barium retention
digitation to assist defecation ▪ Chronic straining: Associated with defecographic
◦ Most patients with external rectal prolapse have findings of spastic pelvic floor or with significantly
associated incontinence increased pelvic floor descent due to pelvic
• Clinical diagnosis of intussusception relies on direct neuropathy
proctoscopy during straining
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Descending Perineum Syndrome (Pelvic
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• Complete rectal prolapse requires surgical treatment
Floor Descent)
Dyskinetic Puborectalis • Defecography provides most accurate estimate of pelvic
• Involuntary contraction and failure of puborectalis floor position and descent
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muscle to relax prevents normal rectal evacuation ◦ Quantified by measuring descent of posterior aspect
◦ Also called spastic pelvic floor syndrome or anismus
of anorectal junction (ARJ) from PCL
•
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Not uncommon cause of obstructed defecation and • Abnormal pelvic floor descent may be seen at rest,
frequently overlooked at imaging but usually occurs during straining due to diminished
• Highly likely that many surgical failures occur in pelvic floor muscle tone
patients treated for rectocele because underlying ◦ Most important factor is extent of descent during
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anismus was not recognized evacuation
◦ Level of ARJ at rest is indicator of muscular tone and
Solitary Rectal Ulcer Syndrome
elasticity of pelvic floor
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• Well-recognized diagnosis that describes combination
▪ Low level of ARJ at rest is suggestive of muscle
of rectal prolapse and functional pelvic floor
abnormality weakness and stretching of fascia
• Other characteristic imaging features include
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• Characterized by repeated unsuccessful straining, often

◦ Elongation of H-line, which represents lengthening
accompanied by passage of blood and mucus
• Pathogenesis of levator hiatus
◦ Caudal angulation of levator plate
◦ Incompletely understood
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◦ ARJ does not to rise above PCL during squeezing

◦ May result from combination of rectal prolapse and
puborectalis dyskinesia Intussusception and Rectal Prolapse
▪ Prolapsed rectal mucosa is forced downward due • Apex of invaginating rectum may be in rectum
://
to pressures generated during defecation and is (intrarectal intussusception), enter anal canal (intraanal
compressed by force of paradoxical puborectalis intussusceptions), or extrude through anal canal (rectal
contraction → mucosal ischemia and ulceration
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prolapse)
• Proctoscopy usually reveals rectal inflammation ◦ MR defecography has advantage of allowing clear
and ulceration, and is accompanied by specific distinction between mucosal intussusception
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histopathological changes within prolapsing mucosa (nonobstructing) and full-thickness rectal

• Precise etiology remains obscure, though it is widely intussusception
believed that ulceration is direct result of mucosal ▪ Infolding of only anterior rectal wall during
ischemia secondary to repeated straining evacuation suggests mucosal intussusception
▪ Commonly seen in association with rectocele and
Congenital Disorders
• most likely represents collapse of rectocele as it
Patients who present with lifelong severe constipation,
empties
and in whom simple therapies have not been effective
• Rectum must empty for intussusception to be revealed
• Congenital disorders include
◦ Intussusception and rectal prolapse occur at end of
◦ Hirschsprung disease
◦ Idiopathic megarectum evacuation
• If intussusception is clinically suspected, it is helpful
◦ Idiopathic megacolon
to obtain images in frontal projection on conventional
IMAGING FINDINGS defecography and coronal images on MR defecography
◦ May not be visible on conventional lateral projection
Rectocele on conventional defecography and sagittal images on
• Anterior rectocele is abnormal bulging of anterior wall MR defecography
of rectum into posterior vaginal wall
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◦ Hirschsprung disease: Narrow distal aganglionic

Dyskinetic Puborectalis
• Lack of descent of pelvic floor during defecation segment of variable length
◦ Congenital megarectum/megacolon: Rectal dilation
• Persistent &/or exaggerated puborectal impression on
posterior aspect of ARJ extends to level of pelvic floor
▪ Normal caliber of sigmoid colon in congenital
• Failure of anorectal angle (ARA) to open → prolonged
and incomplete evacuation megarectum
▪ Dilated sigmoid colon in congenital megacolon
◦ ARA reflects puborectalis activity
◦ Most pertinent finding for diagnosis of anismus is
prolonged and incomplete evacuation RELATED REFERENCES
◦ Using 120 mL of rectal contrast, evacuation times of
1. Bartram C et al: Imaging Pelvic Floor Disorders. 1st ed. New
more than 30 seconds accurately predict functional York: Springer. 159-164, 2003
disorder 2. Delancey JOL: Functional anatomy of the pelvic floor. In
• Long interval between opening of anal canal and start Bartram C et al: Imaging Pelvic Floor Disorders. 1st ed. New
of defecation York: Springer. 27-38, 2003
3. Fielding JR: Practical MR imaging of female pelvic floor
Spastic Anal Sphincter Contraction weakness. Radiographics. 22(2):295-304, 2002
• a.k.a. spasmodic contraction of anal sphincter or anal 4. Beets-Tan RG et al: Measurement of anal sphincter muscles:
sphincter achalasia endoanal US, endoanal MR imaging, or phased-array MR
◦ Under normal circumstances, expansion of rectum imaging? A study with healthy volunteers. Radiology.
t
220(1):81-9, 2001
ne
or rectosigmoid causes internal anal sphincter (IAS)
5. Beets-Tan RG et al: High-resolution magnetic resonance
reflex relaxation (rectal sphincter relaxation reflex)
imaging of the anorectal region without an endocoil.
• Patients usually present with painless constipation Abdom Imaging. 24(6):576-81; discussion 582-4, 1999
associated with dry stools
e.
6. Farag A: Use of the Hagen-Poiseuille law: a new
• Resting anal pressure is significantly higher than mathematical approach for the integration and evaluation
normal on manometry of anorectal physiological testing in patients with faecal
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• Defecography incontinence and pelvic dyschezia and in normal controls.
◦ Anal canal is not open with dilatation of rectum Eur Surg Res. 30(4):279-89, 1998
◦ Resting dilated rectum, or even giant rectum 7. Altringer WE et al: Four-contrast defecography: pelvic "floor-
◦ Barium is not completely emptied oscopy". Dis Colon Rectum. 38(7):695-9, 1995
bg
8. deSouza NM et al: MRI of the anal sphincter. J Comput Assist
• MR Tomogr. 19(5):745-51, 1995
◦ Static MR shows normal anal sphincter muscle
9. Delemarre JB et al: Anterior rectocele: assessment with
complex to exclude IAS hypertrophy
ko
radiographic defecography, dynamic magnetic resonance
◦ Dynamic MR defecography is mandatory to show rate imaging, and physical examination. Dis Colon Rectum.
of evacuation 37(3):249-59, 1994
10. Bartram CI: Evacuation proctography and anal
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Abnormalities of IAS in Patients With endosonography. In: Henry M et al: Coloproctology and the
Obstructed Defecation Pelvic Floor. 2nd ed. Oxford: Butterworth-Heinemann Ltd.
•
146-72, 1992
Abnormally thick IAS is seen in
11. Benson JT: Female Pelvic Floor Disorders. Investigation and
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◦ Solitary rectal ulcer syndrome (invariably present)

Management. New York: Norton, 1992
◦ High-grade intussusception and intraanal
intussusception
◦ Rectal prolapse
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▪ Thick sphincter is indication for evacuation

proctography to exclude rectal prolapse if diagnosis
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has not been made clinically

▪ IAS and submucosa may become elliptical and
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thicker in upper part of canal

▪ Mechanism for this is uncertain and may be
secondary to mechanical stimulation from
prolonged intussusception
▪ Distension from major rectal prolapse may also
damage IAS
◦ Uncomplicated constipation (occasionally)
◦ Hereditary IAS myopathy
▪ Very rare condition
▪ Patients present with episodic anal pain and
chronic constipation
▪ Proctalgia fugax is not uncommon
▪ Grossly thickened IAS
Congenital Disorders
• Water-soluble contrast enema is typically diagnostic of
presence or absence of congenital abnormality
•
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dilation
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ETIOLOGICAL CLASSIFICATION OF CONSTIPATION
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Flow chart summarizes the different causes of constipation according to cause and location of the primary abnormality.
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REPORT TEMPLATE FOR EVACUATION PROCTOGRAPHY
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Graphic provides a simplified template for the reporting of evacuation proctography studies in cases with anorectal dysfunction. A proctographic
report should incorporate an assessment of abnormalities of rectal and pelvic floor configuration (rectocele, pelvic floor descent, prolapse, and
solitary rectal ulcer syndrome) and assessment of functional abnormalities of rectal emptying (inability to empty rectum completely and rapidly).
Normal values are provided for quick reference. Measurements are made during rest, squeezing, straining, and evacuation.
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ANATOMIC CONSIDERATIONS IN RECTOCELE FORMATION
Small bowel
Rectum
Uterus Uterosacral ligament
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Cardinal ligament
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Enterocele
Vagina Rectovaginal fascia

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Rectocele
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Perineal body
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Anus
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Graphic of the female posterior compartment shows an anterior rectocele secondary to a defect in the rectovaginal fascia (RVF), a common
cause for obstructed defecation (OBD). When the RVF is damaged, the cardinal and uterosacral ligaments may be displaced laterally, as
indicated by arrows. The rectal wall balloons anteriorly, obliterates the rectovaginal space, and bulges into the posterior vaginal wall. Damage of
apical fascia may cause an enterocele.
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RECTOCELE ON CONVENTIONAL EVACUATION DEFECOGRAPHY
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Anterior rectocele
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(Top) Conventional defecographic image in a woman with obstructed defecation during straining shows no evidence of rectocele. (Bottom)
Conventional defecographic image in the same patient during evacuation shows a small to moderate anterior rectocele. Asymptomatic small
rectocele is a common finding, but may be considered clinically significant if associated with symptoms, regardless of size.
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MR DEFECOGRAPHY IN RECTOCELE
Vagina
Bladder neck Levator plate

Anorectal junction
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Levator plate
Bladder neck
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Vagina
Anorectal junction
Small rectocele
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Levator plate
Bladder neck
Moderate rectocele Anorectal junction
(Top) Midsagittal dynamic MR defecography during rest in a woman presenting with obstructed defecation shows the anorectal junction and
bladder neck are above the level of the pubococcygeal line (PCL). (Middle) Midsagittal dynamic MR defecography during straining in the same
patient shows descent of the anorectal junction below the PCL and development of small bulge of the anterior rectal wall. The bladder neck
remains above the PCL. There is mild caudal angulation of the levator plate (LP) compared to the resting position. (Bottom) Midsagittal dynamic
MR defecography during evacuation in the same patient shows progressive descent of the anorectal junction below the PCL and enlargement of
the anterior cystocele. The bladder neck remains above the PCL.
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RECTAL INTUSSUSCEPTION AND PROLAPSE
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Intussusception is invagination of the rectal wall, which assumes a circumferential funneling or ring-like configuration during straining. It usually
originates 6-8 cm above the anal canal at the level of the main rectal folds. (2) Intussusception that remains confined to the rectal ampulla is
termed "intrarectal intussusception." (3) Intussusception that enters the anal canal is termed "intraanal intussusception." (4) Rectal prolapse is
diagnosed when the full thickness of the rectal wall is extruded through the anal canal. Since intussusception implies a circumferential process,
invagination confined to the anterior rectal wall should be more accurately termed "anterior rectal wall mucosal prolapse." (1) Normal rectal
appearance is also shown.
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MR OF RECTAL PROLAPSE
Anterior rectocele
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Intrarectal intussusception
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Rectocele
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Cystocele
Uterine prolapse
Rectocele
Intraanal intussusception
(Top) Sagittal image obtained during the early phase of dynamic MR defecography in a patient with a clinical diagnosis of rectal prolapse shows
a small to moderate anterior rectocele and a widely patent anal canal. (Middle) Sagittal image obtained in the same patient on a later phase of
evacuation shows evacuating anterior rectocele and an intrarectal intussusception. The leading edge of the intussusceptum (the leading edge
of the prolapsing rectum) is invaginating into the more distal rectum. (Bottom) Sagittal image obtained in the same patient on a later phase
of evacuation shows a large decompressed anterior rectocele. The leading edge of the intussusceptum is now at the level of the anal canal,
representing an intraanal intussusception. Although the patient presented with a clinical diagnosis of rectal prolapse, the leading edge of the
prolapsing rectum only extended to within the anal canal. There is also cystocele and uterine prolapse.
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MR OF RECTAL PROLAPSE
Prolapsing rectal wall

Rectocele
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Posterior rectal wall

Enfolding of rectal wall
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Anterior rectal wall

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Thickened intussuscepting rectal fold
Anal verge
(Top) Sagittal image obtained during the early phase of dynamic MR defecography in a patient with obstructed defecation shows a moderate
anterior rectocele, large cystocele, and grade II (3-6 cm) uterine descent. (Middle) Sagittal image obtained in the same patient on a later phase
of evacuation shows invagination of both anterior and posterior rectal wall into the anal canal. Repeated evacuation is mandatory to exclude
progressive development of rectal prolapse. Intussusception cannot be excluded without rectal emptying. There is excessive abnormal caudal
angulation of the levator plate with an almost total loss of the levator plate angle. (Bottom) Coronal image in another patient during dynamic MR
defecography shows early invagination of the rectal wall at the level of a thickened rectal fold. Imaging in the coronal plane can be helpful in
some cases in demonstrating intussusception not recognized in the sagittal plane.
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CONVENTIONAL DEFECOGRAPHY IN ANTERIOR RECTAL WALL MUCOSAL PROLAPSE
Rectum
Tip of coccyx
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Anal canal
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Anterior rectal wall

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enfolding
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Posterior anorectal angle

effaced during evacuation
(Top) Resting image from a conventional evacuation proctography study in a patient with obstructed defecation shows a slightly dilated rectum.
(Bottom) Image from a conventional evacuation proctography study in the same patient during rectal evacuation shows infolding of the anterior
rectal wall. As a true intussusception is a circumferential process, isolated involvement of the anterior rectal wall should be more accurately
termed "anterior rectal wall mucosal prolapse."
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MR OF DESCENDING PERINEUM SYNDROME
Anorectal junction
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Rectocele Anorectal junction

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Cystocele
Rectocele Anorectal junction
(Top) Midsagittal image from dynamic MR defecography in a patient presenting with obstructed defecation during rest shows the anorectal
junction just below the PCL. (Middle) Midsagittal image from dynamic MR defecography in the same patient during the early evacuation phase
shows 4 cm of descent of the anorectal junction below the rest position. A small anterior rectocele is present as well. (Bottom) Midsagittal image
from dynamic MR defecography in the same patient during a later phase of evacuation shows further descent of the anorectal junction below the
rest position. An enlarging rectocele and small cystocele are noted. Abnormal pelvic floor descent may be seen at rest, but usually occurs during
straining due to diminished pelvic floor tone.
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MR OF DYSKINETIC PUBORECTALIS AND ANAL SPHINCTER SPASM
Prominent puborectalis muscle
Rectocele
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Prominent puborectalis muscle
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Urethra
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Dilated rectum
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Anorectal angle is effaced

Narrowed anal canal
(Top) Midsagittal dynamic MR defecography in a patient with obstructed defecation during squeezing shows a small anterior rectocele. There
is a prominent puborectalis impression along the posterior rectum as well as a lack of pelvic floor descent. (Middle) Midsagittal dynamic MR
defecography in the same patient during maximum straining shows lack of descent of the pelvic floor, a prominent posterior rectal puborectalis
impression, and failure of the anorectal angle to open. There is also funneling of the urethra. The patient was able to evacuate the ultrasound
gel over 2 minutes. These findings are consistent with dyskinetic puborectalis (anismus). (Bottom) Midsagittal dynamic MR defecography in
another patient with obstructed defecation during maximum straining shows markedly narrowed anal canal lumen. Unlike puborectalis spasm,
the anorectal angle is obtuse, there is adequate descent of the pelvic floor, and the puborectalis muscle is not prominent. This is a case of spastic
anal canal.
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Pelvic Floor MULTICOMPARTMENTAL IMAGING
◦ Urodynamics have been generally accepted as

MULTICOMPARTMENT DEFECTS (MCDS) cornerstone for differentiation of stress from urge UI
Pelvic Floor Dysfunction (PFD) ◦ Correlation between urodynamic findings and UI
• Each organ system in pelvis, urinary, genital, and symptoms is generally poor, particularly in patients
intestinal traverses pelvic floor at levator hiatus and has with symptoms of mixed UI
its own perineal orifice 3-Axis Perineal Evaluation (TAPE)
◦ These systems are intricately related in function and
• Beco & Mouchel introduced 3-axis approach in 2003 in
structural support attempt to improve diagnosis
• Among women with PFD, 95% have abnormalities in ◦ Also called perineology
all 3 pelvic compartments ◦ TAPE is recommended in assessment of a patient with
◦ May present with symptoms that relate to only 1
PFD, even if main symptom is apparently related to
compartment only 1 pelvic compartment
• Clinically, disorders of each compartment should be ◦ Created and designed to summarize functional state
evaluated in regard to surrounding structures and of patient's perineum
functional anatomy of pelvic floor • Thorough clinical evaluation of all 3 compartments is
• Most common forms of dysfunction are urinary necessary regardless of patient symptomology
incontinence (UI), pelvic organ prolapse (POP), and ◦ Patients may present with symptoms isolated to
fecal incontinence 1 pelvic floor compartment but majority have
◦ Women are affected 3-7x more often than men
t
concomitant defects in other compartments
ne
◦ It is estimated that 23.7% of women in USA have
◦ Surgical failures and reoperation have been attributed
some degree of PFD to lack of thorough preoperative evaluation and
◦ Reported rate of reoperation for incontinence and
inadequate diagnosis and staging of PFD
e.
prolapse is 29%, suggesting need for advances in both • Main objective of TAPE is restoration of anatomy with
diagnosis and treatment of these disorders respect to biomechanics and physiology
• Physicians treating women with PFD should adopt a ◦ Each defect must be corrected without inducing new
yn
global approach, taking into consideration all 3 pelvic support structure weakness
compartments ◦ Risks and benefits must be evaluated for each
◦ Not only urologist, gynecologist, and proctologist,
procedure
but a "perineologist" with a thorough understanding
bg
• Application of TAPE
of all pelvic support system defects ◦ Thorough patient history is obtained and clinical
▪ Subspecialized expertise is necessary to obtain
evaluation performed
ko
pertinent history and perform appropriate ◦ Findings are plotted on 3 intersecting axes; common
perineal/pelvic exam perineal disorders are represented on ends of each
◦ Radiologist must have understanding of clinical
axis
oo
presentations and detailed knowledge of normal ▪ Gynecologic axis, representing dyspareunia and
anatomy and findings in dysfunction prolapse
◦ Multidisciplinary conference should be held to
▪ Urologic axis, representing dysuria and
incorporate clinical and imaging data
eb
incontinence
• Paradigm shift in both diagnosis and treatment of PFD ▪ Coloproctologic axis, representing dyschezia and
◦ No longer treat only the prolapsed organ(s), but now
fecal incontinence
treat underlying pelvic support system defects ◦ Each perineal condition is assigned a level of severity
://
• Wide variety of surgical procedures are used, with based on clinical findings
several based only on weak scientific evidence ▪ 0 = not present
◦ By defining damage to all support mechanisms/
tp
▪ 1 = mild
compartments, better treatment plans and targeted ▪ 2 = severe
therapies can be employed ◦ Plot for a normal patient with no perineal disorder
ht
◦ Optimal approach to treatment must be

will be hexagonally shaped
individualized based on both symptoms and specific ◦ Plot serves as a visual representation of complex
anatomical and structural abnormalities multicompartment perineal disorders
▪ Response to treatment can be easily appreciated by
CLINICAL ASSESSMENT OF MCDS changes in plot appearance
Physical Exam
• Standard examination has well-recognized limitations
IMAGING OF MCDS
◦ Difficulty in differentiating high-grade cystocele from
General
enterocele, vaginal vault prolapse, or high rectocele • Goals of imaging examination are 2-fold
◦ Enteroceles may be difficult to detect because of
◦ Identify presence and degree of organ prolapse
vaginal overcrowding ◦ Identify defects in supporting structures
◦ Clinical findings may not correlate with symptoms if
• MR has essential role in preoperative imaging
patient has deep pelvis, as extent of prolapse may not evaluation of MCD and may have considerable impact
be appreciated on operative procedures
• Accuracy of symptom-based diagnosis of UI is limited, ◦ Improved imaging of detailed support structures
though there have been attempts to improve both has resulted in better understanding of structural
8 objectivity and reliability relationships
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MULTICOMPARTMENTAL IMAGING
Pelvic Floor
▪ Treating prolapsing organ(s) without fixing ▪ Many patients with UI have concomitant
supporting structure is ineffectual symptoms of pelvic outlet obstruction and
▪ All sites of weakness or defect should be reported, obstructed defecation
not just those of symptomatic compartment • MR imaging findings serve as important guide for
▪ Neglected or undiagnosed defects in other therapy
compartments result in incomplete treatment ◦ Physiotherapy for patient with global muscle
(e.g., high-grade cystocele may mask stress urinary weakness and normal fascia
incontinence [SUI]) ◦ Surgical repair for patient with focal fascial defect &/
◦ MR ideally suited to simultaneously depict all 3 pelvic or muscle tear
compartments
▪ Provides significant information beyond that CORRELATIVE ANALYTIC APPROACH
obtained by physical exam in up to 60% of patients
◦ Dynamic sequences also evaluate function, not solely Data Integration
• Correlative analytical approach integrates both static
anatomy
• Postoperative indications and dynamic MR imaging findings
◦ Persistent symptoms, which may indicate • Combining TAPE with MR analytical approach provides
unsuccessful surgery complete assessment of patient, both clinically and
◦ Recurrent symptoms after a period of improvement radiologically
◦ New symptoms that were not present before surgery ◦ Provides a common language through which
t
◦ Postoperative complication of obstructed urination radiologist can effectively communicate imaging
ne
or hemorrhage findings
• Diagnostic algorithm should be used as a guideline to
Combined Static and Dynamic MR tailor imaging evaluation according to symptoms and
e.
• Both static and dynamic sequences are necessary for clinical findings
complete evaluation • Standardized MR reporting system is necessary
• Requires correlation between static and dynamic ◦ Detailed checklist to ensure complete evaluation
yn
sequences to determine whether a particular ◦ Structured reporting improves communication with
anatomical defect on static images is associated with referring clinicians
specific dysfunction on dynamic images • This approach enhances collaboration and interaction
bg
◦ Correlative analysis has advanced understanding between radiologist and clinician to optimize patient
of PFD by linking symptoms to specific structural care
defects
Treatment
ko
◦ Can more precisely identify underlying anatomical
• Goal is to reduce complications and improve outcomes
defects responsible for PFD symptoms for each
• Comprehensive integrated evaluation allows for defect-
individual patient
oo
• Anterior compartment specific therapeutic approaches, minimizing risk of

◦ SUI surgical failure, dysfunction recurrence, and need for
▪ Associated with structural defects in urethral reoperation
◦ 2 patients may have similar symptoms but different
eb
supporting elements, not with bladder neck

descent anatomic defects that require unique therapies
• Middle compartment
◦ Integrated MR analytical approach makes it possible RELATED REFERENCES
://
to differentiate whether POP is caused by defects in

endopelvic fascia, levator muscle weakness, or both of anatomic and functional abnormalities. Radiographics.
tp
◦ Cystocele
34(2):429-48, 2014
▪ Term is often used for all types of bladder base 2. García Del Salto L et al: MR Imaging-based assessment of the
descent, which is imprecise and incomplete; must
ht
female pelvic floor. Radiographics. 34(5):1417-39, 2014

define specific site for appropriate repair 3. El Sayed RF: The urogynecological side of pelvic floor MRI:
▪ Requires dynamic imaging not only at midline, but the clinician's needs and the radiologist's role. Abdom
parasagittal images are necessary to identify precise Imaging. 38(5):912-29, 2013
anatomic area of weakness 4. El Sayed RF et al: Pelvic floor dysfunction: assessment with
▪ Cystocele repair without attention to rest of pelvic combined analysis of static and dynamic MR imaging
findings. Radiology. 248(2):518-30, 2008
floor may predispose patient to increased incidence 5. Petros PEP: Reconstructive pelvic floor surgery according to
of enterocele, rectocele, or uterine prolapse after the integral theory. In: Petros PEP: The Female Pelvic Floor
surgery Function, Dysfunction, and Management According to the
• Posterior compartment Integral Theory. 2nd ed. Heidelberg: Springer. 83-167, 2007
◦ Many patients with urinary incontinence (UI) or 6. Hübner M et al: A prospective comparison between
uterovaginal prolapse have coexistent anorectal clinical outcome and open-configuration magnetic
dysfunction resonance defecography findings before and after surgery
▪ Fecal incontinence may be as high as 17% in for symptomatic rectocele. Colorectal Dis. 8(7):605-11, 2006
7. El Sayed RF et al: Preoperative and postoperative magnetic
patients with UI and POP resonance imaging of female pelvic floor dysfunction:
▪ Greater degrees of prolapse are associated with a
correlation with clinical findings. J Women’s Imaging
greater probability of fecal incontinence 7:163–180, 2005
8. Beco J et al: Perineology: a new area. Urogynaecol Int J.
17:79–86, 2003 8
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CLINICAL ASSESSMENT OF PELVIC FLOOR DYSFUNCTION
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ko
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(Top) This clinical examination sheet can be used to record examination findings. Each structure is assessed and noted, with the degree of pelvic
organ prolapse (POP) recorded. (Middle) The 3-axis perineal evaluation (TAPE) is a plot to graphically represent the functional state of the
perineum. Each of the 3 axes reflects a spectrum of related perineal pathologies. The gynecologic axis is in red, encompassing dyspareunia and
prolapse. The urologic axis is in yellow, representing dysuria and urinary incontinence. The coloproctologic axis is in pink, reflecting dyschezia
and fecal incontinence. For each axis, there are 3 levels of severity: 0 = not present, 1 = mild, 2 = severe. (Bottom) This TAPE is of a patient with
problems on all 3 axes: Mild dyspareunia, severe fecal incontinence, and mild urinary incontinence. Knowing the physical exam findings and
patient symptoms helps the radiologist tailor the MR exam and address the specific complaint.
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CORRELATIVE ANALYTIC APPROACH OF STATIC AND DYNAMIC MR IMAGING
This correlative analytical approach, with standardized reporting, converts static and dynamic MR from 2 separate types of images into an
integrated system. This has multiple benefits: (1) more precise identification of the underlying anatomical defect(s) responsible for patient
symptoms, (2) improved communication between the radiologist and clinician when discussing complex disorders, (3) individualized defect-
specific approaches to treatment, which may minimize the risk of surgical failure, dysfunction recurrence, and reoperation.
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DIAGNOSTIC ALGORITHM FOR MR IMAGING
This diagnostic algorithm can be used as a guideline to help tailor imaging according to the patient's symptoms and the clinical findings. The
radiologist should be aware that defects in multiple compartments are present in 90% of patients with pelvic floor dysfunction (PFD). It is
essential to consider all 3 pelvic compartments as an integrated unit.
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SYMPTOMS: SUI; DIAGNOSIS: 3-COMPARTMENT POP
Uterus
Levator plate
No uterine descent
Cystocele formation
Anterior rectocele
Newly developed uterine descent
Worsening cystocele
Mild increase of anterior rectocele
(Top) Sagittal BFFE MR shows a female patient whose sole complaint is stress urinary incontinence (SUI). At rest, the urinary bladder and
bladder neck are in normal position. The anterior abdominal wall is relaxed, denoting that the patient is not straining. The levator plate is
normally angulated. (Middle) Sagittal BFFE MR in the same patient during mild straining shows bladder base descent, no uterine descent, and
a small anterior rectocele. When an anterior rectocele is noted, MR defecography is indicated to confirm whether the rectocele empties with
evacuation. (Bottom) Sagittal BFFE MR in the same patient during maximum straining demonstrates an obvious increase in the cystocele size,
newly developed uterine descent, and a mild increase in rectocele size. The patient presented with only SUI but had multicompartmental POP.
Involvement of multiple compartments will significantly alter therapy.
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SYMPTOMS: BACK PAIN; DIAGNOSIS: 3-COMPARTMENT POP
Relaxed abdominal wall
Levator plate angle (LPA)
LPA
Vagina opacified by gel
Bulging abdominal wall during

maximum straining
LPA
Uterine descent
Anterior rectocele
(Top) Sagittal BFFE MR was obtained at rest in a patient with back pain who also had a bulging vaginal mass upon clinical examination.
There is a normal levator plate angle (LPA) and no evidence of POP. Note the straight anterior abdominal wall, confirming that the patient is
at rest, a helpful clue to monitor the patient's compliance with instructions. (Middle) Sagittal BFFE MR in the same patient during moderate
straining shows descent of multiple pelvic organs. It is important for the radiologist to be an active participant in these cases and act as a coach,
encouraging the patient to comply with instructions. (Bottom) Sagittal BFFE MR in the same patient during maximum straining demonstrates an
increase in severity of the POP in all 3 compartments without evidence of other masked pathology. In this case, it is important to note that there
is only moderate increase in the LPA. There were no fascial or ligamentous abnormalities on static images; therefore, this patient may benefit
from physiotherapy.
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SYMPTOMS: SUI; DIAGNOSIS: POP AND INTUSSUSCEPTION
Bulging anterior abdominal wall
Urine loss
Rectal wall infolding
Continued urine loss
Anterior rectal wall infolding

Open anal canal
(Top) Dynamic MR in a patient complaining of SUI shows a bulging anterior abdominal wall, indicating that this image is not obtained at rest.
This is a sequence of images taken during evacuation. (Middle) With continued evacuation, there is increasing urine loss, which was the patient's
presenting complaint. Uterine descent has not significantly changed. The most important (and unexpected) finding is anterior and posterior
infolding of the rectal wall (rectal intussusception). (Bottom) The latest stage of evacuation shows that the anal canal is fully open and opacified
with intrarectal gel. With evacuation, the anterior rectal fold becomes thicker. Identification of all of these findings is imperative for appropriate
treatment.
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SYMPTOMS: SUI; DIAGNOSIS: MUSCLE WEAKNESS
Mild enlargement of levator

hiatus at rest
Marked ballooning of
puborectalis muscle with
straining
Excessive elongation of
iliococcygeus muscle during
maximum straining
Iliococcygeus muscle at rest
Normal level III fascia Normal midline urethra
Mild paravaginal level II

fascial defect
Mild paravaginal level I
fascial defects
(Top) Axial (upper) and coronal (lower) BFFE MR images in the same patient are shown at rest (left images) and during maximum straining (right
images). The axial maximum straining images show marked puborectalis ballooning, and the coronal maximum straining image demonstrates
severe sagging of the iliococcygeus muscle slings on both sides. It is imperative that the static portion of this study be performed to determine
the underlying cause of POP. (Bottom) Static T2WI MR images of the same patient show an essentially normal urethral support system with very
minor paravaginal fascial defects at levels I and II. Correlation between static and dynamic findings shows that POP is due to muscle weakness,
not a fascial defect. Physiotherapy is the treatment of choice, not surgical repair of the fascia.
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SYMPTOM: SUI; DIAGNOSIS: MULTIPLE FASCIAL DEFECTS
Level III fascial defect with

drooping mustache sign of
fat in the space of Retzius
Widened levator hiatus with

strain
Mild level II fascial defect

Mild level I fascial defect
Torn suburethral ligaments
Levator hiatus Detached left vaginal wall

fascia
Prolapsed cervix seen at

bladder neck
Level I paravaginal defect

Intussuscepting vaginal wall (saddlebag sign)
Level II paravaginal defect
(Top) Multiple axial T2WI MR images were obtained in a patient presenting with SUI. Axial MR during straining (top left) shows widening of the
levator hiatus. The remaining static images show defects at all 3 levels, with the most significant being at the level III fascia. (Bottom) Multiple
axial T2WI MR images were obtained in a different patient presenting with SUI. The top left image shows widening of the levator hiatus with
straining. The remaining static images show damage to the supporting structures at all 3 levels. There is a torn suburethral ligament bilaterally
with an abnormal left vaginal contour, as well as large left paravaginal defects of the level I and level II fascia. While both patients presented with
SUI, the symptomology was due to different underlying defects, and different operative approaches were required.
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SYMPTOMS: SUI; DIAGNOSIS: POP AND SIGMOIDOCELE
Normal LPA
Increased LPA
Small cystocele
Marked caudal angulation of levator

plate
Marked bladder base descent
Large sigmoidocele
(Top) Sagittal BFFE MR in a patient who complained of SUI demonstrates no evidence of POP. During rest, the bladder and uterus are above
the PCL. There is a normal LPA. (Middle) Sagittal BFFE MR in the same patient during moderate straining shows a mild cystocele and no uterine
descent. Note the obvious increase of the LPA. (Bottom) Sagittal BFFE MR in the same patient during evacuation demonstrates marked POP in all
3 pelvic compartments. There is severe bladder base descent, mild uterine descent, and a large sigmoidocele with severe sagging of the levator
plate. For a complete evaluation, there needs to be assessment of all 3 pelvic compartments, even if the patient's symptoms refer only to a single
compartment.
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SYMPTOM: RECTAL PROLAPSE; DIAGNOSIS: SPHINCTER DEFICIENCY AND LEVEL I FASCIAL DEFECT
Deep external anal sphincter (DEAS)
IAS deficiency
IAS
DEAS
Level I fascial defect
(Top) Axial T2WI MR shows a patient who presented with rectal prolapse. In cases of rectal prolapse, it is imperative to include the anal
sphincter in the imaging evaluation. In this case, there is marked thinning of the internal anal sphincter (IAS) along its posterior aspect from the
4- to 7-o'clock position. The deep external anal sphincter (DEAS) shows diminished muscle bulk; however, there is no definite focal defect.
(Middle) Axial T2WI MR in the same patient, at a slightly higher level at the upper 1/3 of the DEAS, demonstrates diminished bulk of the external
sphincter, with a preserved IAS. (Bottom) Axial T2WI MR in the same patient demonstrates a right paravaginal level I facial defect with a bulging
contour of the right bladder wall. Defects are often present in different compartments from that of the presenting symptom, dramatically altering
therapy.
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COMPETITIVE ORGAN CONCEPT
Normal-appearing levator plate

musculature
Kinking of urethra, preventing urine

leakage
Large rectocele
Marked anorectal junction descent
Cystocele
Uterine prolapse
Urethral kinking
Increased LPA
Large rectocele
(Top) Dynamic sagittal BFFE MR was obtained at rest in a patient whose main complaint was a large bulging perineal mass and obstructed
defecation. The pelvic organs are normal in position, and the levator plate has normal thickness and angulation. (Middle) Dynamic sagittal
BFFE MR during moderate straining in the same patient shows a moderately sized cystocele, mild uterine descent, and large rectocele. Note
the kinked urethra, which will mask underlying SUI. (Bottom) Dynamic sagittal BFFE MR during maximum straining in the same patient
demonstrates slight enlargement of the rectocele. The uterine descent and cystocele are unchanged but are most likely more severe than they
appear, as further descent is precluded by the large rectocele. In the competitive organ concept, the most advanced POP may reduce the
severity of other POPs and mask symptoms. If surgical repair is only done on the rectocele, the patient will likely present postoperatively with
SUI and uterine prolapse.
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ENLARGING RECTOCELE AFTER SUI SURGERY
Abnormal right vaginal wall contour

due to fascial detachment
Thinned iliococcygeus muscle
Uterine prolapse
Cystocele
Anterior rectocele
Catheter in rectum
Large rectocele
(Top) Axial T2WI MR in a patient who presented with the sole complaint of SUI shows detachment of the right vaginal wall fascial support and
marked thinning of the right iliococcygeus muscle. (Middle) Preoperative dynamic sagittal BFFE during maximum straining in the same patient
revealed not only a mild cystocele, but also uterine prolapse and an anterior rectocele. Surgery was done for her SUI but it did not address the
multicompartment POP and rectocele. (Bottom) Postoperative dynamic sagittal BFFE shows the same patient 1 year later. The patient has new
complaints of obstructed defection and fecal incontinence. When compared to preoperative imaging, there has been a significant increase in the
size of the anterior rectocele. All MR findings must be reported and taken into consideration when planning surgical repair. Failure to address all
compartments, as in this case, will result in incomplete treatment and necessitate repeat surgical intervention.
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Untitled-1 1 14-08-15 12:40 PM

INDEX
INDEX
INDEX
18-Fluorodeoxyglucose (FDG-18) PET/CT. See PET/ pathology
CT technique and imaging issues. general features, 4:36
46,XX disorders of sexual development, ambiguous gross pathology & surgical features, 4:36
genitalia associated with, 7:18 microscopic pathology, 4:36–37
46,XY disorders of sexual development treatment options by stage, 4:38
ambiguous genitalia associated with, 7:18 Adenofibroma and cystadenofibroma, ovarian,
dysgerminoma associated with, 5:129 5:74–79
A
Adenoid basal carcinoma, 3:30
Adenoid cystic carcinoma, 3:30
Adenoma malignum, cervical, 3:50–54
cervical glandular hyperplasia associated with,
Abnormal sexual development. See Sexual 3:65
development, abnormal. differential diagnosis, 3:51
Actinomycosis, fallopian tubes, 6:26–29 nabothian cysts vs., 3:69
differential diagnosis, 6:27 Adenomatous polyp, adenosarcoma vs., 2:111
genital tuberculosis vs., 6:24 Adenomyoma, uterine, 2:198–201
Acute adnexal torsion, 5:236–241 differential diagnosis, 2:199–200
differential diagnosis, 5:237–238 focal, degenerated leiomyoma vs., 2:74
hemorrhagic ovarian cyst vs., 5:29 polypoid, endometrial polyps vs., 2:101
massive ovarian edema and fibromatosis vs., 5:243 uterine leiomyoma vs., 2:68
ovarian mixed germ cell tumor, embryonal Adenomyomatous polyp, adenomyoma vs., 2:200
carcinoma and polyembryoma vs., 5:145 Adenomyosis, uterine, 2:192–197
ovarian vein thrombosis vs., 5:228 adenosarcoma vs., 2:111
pelvic inflammatory disease vs., 6:7–8 cystic. See Cystic adenomyosis, uterine.
pyosalpinx vs., 6:15 deep, Asherman syndrome, endometrial
tubo-ovarian abscess vs., 6:19 synechiae associated with, 2:55
with massive ovarian edema, ovarian differential diagnosis, 2:194
hyperstimulation syndrome vs., 5:209 diffuse, adenomyoma associated with, 2:200
Adenocarcinoma, Bartholin gland: Bartholin cysts endometrial stromal sarcoma vs., 2:143
vs., 4:88 endometrioma associated with, 5:191
Adenocarcinoma, cervical endometriosis associated with, 5:201
cervical glandular hyperplasia vs., 3:65 focal, degenerated leiomyoma vs., 2:74
clear cell malignant mixed mesodermal tumor vs., 2:116
general features, 3:29 salpingitis isthmica nodosa vs., 6:31
microscopic pathology, 3:30 segmental, adenomyoma vs., 2:199
endometrioid, microscopic pathology, 3:30 uterine leiomyosarcoma vs., 2:121
general features, 3:28 Adenomyotic cysts, congenital uterine cysts vs., 2:53
microscopic pathology, 3:29–30 Adenosarcoma
poorly differentiated, microscopic pathology, müllerian, endocervical polyp vs., 3:13
3:29–30 uterine, 2:110–113
villoglandular, microscopic pathology, 3:30 Adnexal mass, cystic
Adenocarcinoma, mucinous ovarian: clear cell degenerated leiomyoma vs., 2:74
carcinoma vs., 5:99 nabothian cysts vs., 3:69
Adenocarcinoma, tubal: tubal leiomyoma vs., 6:35 Adnexal torsion, acute. See Acute adnexal torsion.
Adenocarcinoma, vaginal Aggressive angiomyxoma, vulvovaginal, 4:76–79
endometrioid, 4:37 Air in vagina, foreign bodies vs., 4:104
mesonephric, 4:37 Alveolar soft part sarcoma, cervical, 3:55
mucinous, microscopic pathology, 4:37
Obgyne Books Full i
DI2GYN_Index_Oct.10.2014.indd 1 10/10/2014 3:12:06 PM

INDEX
Ambiguous genitalia, 7:16–19. See also Sexual rectal evacuation abnormalities associated with,
INDEX
development, abnormal. 8:113

differential diagnosis, 7:18 Anorectal dysfunction
genetics, 7:18 anorectal physiology tests, 8:89
uterine hypoplasia/agenesis vs., 2:21 anorectal manometry, 8:89
Amenorrhea, thecoma associated with, 5:162 electromyography, 8:89
Ampulla, fallopian tubes: anatomic relationship, 2:3 motor-evoked potentials, 8:89
Anal canal anatomy. See Rectum and anal canal pudendal nerve terminal motor latency test,
anatomy. 8:89
Anal continence, factors contributing to, 8:88 Sitzmarks transit study, 8:89
Anal sphincter and pelvic floor, clinical clinical evaluation, 8:88–89
examination, 8:89 assessment of anal sphincter and pelvic floor,
Anal sphincter complex, 8:95–99 8:89
anatomy, 8:88 constipation and obstructed defecation, 8:89
graphic, 8:95 fecal incontinence, 8:88–89
atrophy, image findings, 8:103 dynamic and static phased-array MR, 8:89–90
axial oblique BFFE MR, 8:96 dimensions of anal sphincter complex, 8:90
coronal T2WI MR, 8:95 imaging planes and field of view, 8:89
defects and scar tissue, image findings, 8:102–103 MR appearance of anal sphincter complex,
dynamic and static phased-array MR 8:89–90
dimensions of ASCx, 8:90 technique, 8:89
identifying components of ASCx on topographic MR anatomy, 8:90
sequential axial images, 8:90 Sitzmarks transit study, 8:89
MR appearance of ASCx, 8:89–90 Anorectal manometry, for anorectal dysfunction,
topographic MR anatomy, 8:90 8:89
endoanal MR, 8:91 Anorectal region physiology, 8:88
endoanal sonography, 8:92 factors contributing to anal continence, 8:88
external anal sphincter. See External anal rectoanal inhibitory reflex, 8:88
sphincter. Anovulation, chronic: endometrial carcinoma
graphic, 8:95 associated with, 2:128
internal anal sphincter. See Internal anal sphincter. Anterior compartment of pelvic floor. See Pelvic
intersphincteric space and longitudinal smooth floor anterior compartment imaging; Pelvic
muscle layer, 8:88 floor anterior compartment overview.
MR appearance, 8:96–99 Anterior pelvic wall, anatomy, 8:2
puborectalis muscle, 8:88 Anterior rectal wall mucosal prolapse, conventional
graphic, 8:96 defecography of, 8:123
structural abnormalities (graphic), 8:106 Anterior vaginal wall prolapse, 8:68–69
surgical damage, fecal incontinence associated Anterior vaginal wall support, normal, 8:68
with, 8:102 Appendiceal mucocele, hydrosalpinx vs., 6:11
Anal sphincter contraction, spastic: rectal Appendicitis
evacuation abnormalities associated with, 8:113 ovarian vein thrombosis vs., 5:228
Anal triangle of perineum, 8:6 perforated, pelvic inflammatory disease vs., 6:7–8
Androblastoma. See Sertoli-stromal cell tumors. Arcuate uterus, 2:48–49
Androgen insensitivity syndrome, 7:14–15. See also bicornuate uterus vs., 2:39
Sexual development, abnormal. class VI müllerian duct anomaly, 2:49
differential diagnosis, 7:15 DES exposure vs., 2:51
genetics, 7:15 septate uterus vs., 2:43
gonadal dysgenesis vs., 7:21 Arcus tendineus fascia pelvis (ATFP) ligament, 8:5
uterine hypoplasia/agenesis vs., 2:21 Arcus tendineus levator ani (ATLA) ligament, 8:5
Angiolipoleiomyoma, subtype of lipomatous uterine Arias-Stella reaction, cervical glandular hyperplasia
tumors, 2:97 vs., 3:65
Angiomyofibroblastoma, vulvar: aggressive Arrhenoblastoma. See Sertoli-stromal cell tumors.
angiomyxoma vs., 4:77 Arteriovenous malformation. See Uterine
Angiomyxoma, aggressive, vulvovaginal, 4:76–79 arteriovenous malformation.
Anorectal congenital anomalies Asherman syndrome, endometrial synechiae,
fecal incontinence associated with, 8:102 2:54–57
image findings, 8:114 DES exposure vs., 2:51
differential diagnosis, 2:55
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Assisted reproductive technique, hematosalpinx septate uterus vs., 2:43
INDEX
associated with, 6:55 staging, grading, & classification, 2:40
Atypical melanotic nevus, genital type: vulvar unicollis, uterus didelphys vs., 2:33
melanoma vs., 4:73 unicornuate uterus vs., 2:27
B
Bilateral tubal ligation. See Contraceptive device
evaluation.
Bladder. See Urinary bladder.
Blood flow stasis, ovarian vein thrombosis
B-cells, polyclonal activation by infection: genital associated with, 5:228
lymphoma associated with, 7:3 Bony pelvis
Bartholin cysts, 4:86–89 anatomy (graphic), 8:7
Bartholin gland carcinoma vs., 4:55 functional correlation, 8:2
bartholinitis vs., 4:91 osseous structures, 8:2
differential diagnosis, 4:87–88 Bowel, ovarian dermoid (mature teratoma) vs., 5:116
Gartner duct cysts vs., 4:83 BRCA1 and BRCA2 gene mutation, fallopian tube
Merkel cell tumor vs., 4:81 carcinoma associated with, 6:44
Skene’s gland cyst vs., 4:99 Breast cancer, ovarian carcinoma associated with,
urethral diverticulum vs., 4:95 5:47
vulvar hemangioma vs., 4:25 Brenner tumors. See also Ovarian transitional cell
Bartholin gland adenocarcinoma, Bartholin cysts carcinoma.
vs., 4:88 clinical issues, 5:110–111
Bartholin gland carcinoma, 4:54–55 differential diagnosis, 5:109–110
bartholinitis vs., 4:91 fibroma, thecoma, and fibrothecoma vs., 5:161
differential diagnosis, 4:55 imaging, 5:109
Bartholinitis, 4:90–93 microscopic features, 5:110
aggressive angiomyxoma vs., 4:77 mucinous cystadenoma associated with, 5:70
Bartholin cysts vs., 4:87 pathology, 5:110
differential diagnosis, 4:91 Broad ligament hematoma or phlegmon, ovarian
Benign cystic ovarian teratoma, lipomatous uterine vein thrombosis vs., 5:228
tumors vs., 2:97 Broad ligament leiomyoma. See Parasitic uterine
Benign (multi) cystic peritoneal mesotheliomas. See leiomyoma.
Peritoneal inclusion cysts. Burkitt lymphoma, genital lymphoma associated
Benign endometrial stromal nodule, endometrial with, 7:3
C
stromal sarcoma vs., 2:143
Benign metastasizing leiomyoma, 2:84–85
intravenous leiomyomatosis vs., 2:91
Benign mucinous cystadenoma. See Mucinous C-section scar. See Post cesarean section appearance
cystadenoma, ovarian. of uterus.
Benign papillary peritoneal cystosis. See Peritoneal CA125 tumor marker, for diagnosis, assessment and
inclusion cysts. treatment response of fallopian tube carcinoma,
Benign pelvic lipoma, lipomatous uterine tumors 6:44
vs., 2:97 Carcinoid, ovarian, 5:140–143
Benign serous cystadenoma. See Serous differential diagnosis, 5:141
cystadenoma, ovarian. mucinous cystadenoma associated with, 5:70
Benign uterine neoplasms. See Uterine neoplasms. Carcinosarcoma
Benign vulval conditions, vulvar leiomyosarcoma malignant mixed, cervical, 3:55, 56
vs., 4:71 ovarian (ovarian mixed müllerian tumor),
Bicornuate uterus, 2:38–41 5:104–107
arcuate uterus vs., 2:49 differential diagnosis, 5:105
associated abnormalities, 2:40 staging, grading, & classification, 5:105
bicollis, uterus didelphys vs., 2:33 uterine. See Malignant mixed mesodermal tumor,
class IV müllerian duct anomaly, 2:39 uterine.
differential diagnosis, 2:39 Cavernous hemangioma. See Uterine arteriovenous
noncommunicating horn, congenital uterine malformation.
cysts vs., 2:53 Cervical adenocarcinoma
cervical glandular hyperplasia vs., 3:65
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clear cell gross pathology and surgical features, 3:29
INDEX
general features, 3:29 microscopic pathology, 3:29–31

microscopic pathology, 3:30 risk factors, 3:29
endometrioid, microscopic pathology, 3:30 routes of spread, 3:28
general features, 3:28 reporting checklist, 3:35
microscopic pathology, 3:29–30 staging
poorly differentiated, microscopic pathology, AJCC Stages/Prognostic Groups, 3:21
3:29–30 (T), 3:20
villoglandular, microscopic pathology, 3:30 (N), 3:20
Cervical adenoma malignum, 3:50–54 (M), 3:20
cervical glandular hyperplasia associated with, imaging findings, 3:32–33
3:65 restaging, 3:33–34
differential diagnosis, 3:51 metastases, organ frequency, 3:27
nabothian cysts vs., 3:69 methods for microscopic measurement of
Cervical anatomy, 3:2–7 depth of invasion, 3:22
anatomy imaging issues, 3:3 N1, 3:27
cervical pathology, 3:3 reporting checklist, 3:35
clinical implications, 3:3 T1a1, 3:22, 24
CT, 3:7 T1a2, 3:23, 24
embryology, 3:3 T1b1, 3:23, 24
graphics T1b2, 3:24
sagittal illustration, 3:4 T2a1 and T2a2, 3:25
transverse illustration, 3:4 T2b, 3:25
gross anatomy, 3:2 T3, 3:23
imaging anatomy, 3:2–3 T3a, 3:25
MR, 3:5 T3b, 3:26
zonal anatomy, 2:12 T4, 3:26
ultrasound, 3:6 Tis, 3:22
Cervical blood clot, endocervical polyp vs., 3:13 staging (images), 3:37–49
Cervical carcinoma, 3:20–49 central recurrence, 3:48
cervical sarcoma vs., 3:55 cystic pelvic sidewall recurrence, 3:48
classification, 3:28 distant recurrence, 3:48
clinical issues, 3:34–35 pelvic sidewall recurrence, 3:48
natural history and prognosis, 3:34 recurrence, 3:49
presentation, 3:34 stage IB1 (T1b1 N0 M0), 3:37
treatment options by stage, 3:34–35 stage IB2 (T1b2 N0 M0), 3:37–38
genital lymphoma vs., 7:3 stage IIA1 (T2a1 N0 M0), 3:38–39
image gallery, 3:37–49 stage IIA1 (T2a2 N0 M0), 3:39–40
imaging findings, 3:31–34 stage IIB (T2b N0 M0), 3:40–41
detection, 3:31–32 stage IIIA (T3a N0 M0), 3:41
restaging, 3:33–34 stage IIIB (T1b1 N1 M0), 3:41
staging, 3:32–33 stage IIIB (T2b N1 M0), 3:41–42
microscopic pathology stage IIIB (T3b N0 M0), 3:42–43
adenocarcinoma, 3:29–30 stage IIIB (T3b N1 M0), 3:44
adenoid basal carcinoma, 3:30 stage IIIB with bullous edema sign, 3:44
adenoid cystic carcinoma, 3:30 stage IVA (T4 N0 M0), 3:44–45
atypical carcinoid, 3:30 stage IVB (T1b2 N1 M1), 3:45–46
histologic grade, 3:30–31 stage IVB (T2a N1 M1), 3:47
immunohistochemistry, 3:31 stage IVB (T2a2 N0 M1), 3:46
large cell neuroendocrine carcinoma, 3:30 stage IVB (T2a2 N1 M1), 3:46
neuroendocrine tumors, 3:30 stage IVB (T2b N0 M1), 3:46
PCR, 3:31 stage IVB (T2b N1 M1), 3:47
small cell neuroendocrine carcinoma, 3:30 vaginal leiomyoma vs., 4:19
squamous cell carcinoma, 3:29 with vaginal extension, vaginal leiomyosarcoma
overview, 3:28 vs., 4:45
pathology, 3:28–31 Cervical congenital anomalies, cervical stenosis vs.,
general features, 3:28–29 3:9
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Cervical endometriosis natural history and prognosis, 3:56
INDEX
cervical glandular hyperplasia vs., 3:65 pathology, 3:55–56
cervical stenosis associated with, 3:9 alveolar soft part sarcoma, 3:55
Cervical fibroma. See Cervical leiomyoma. Ewing sarcoma, 3:55
Cervical glandular hyperplasia, 3:64–67 leiomyosarcoma, 3:55
differential diagnosis, 3:65 liposarcoma, 3:55, 56
with gastric metaplasia, adenoma malignum vs., malignant mixed carcinosarcoma tumors, 3:56
3:51 malignant peripheral nerve sheath tumor, 3:55
Cervical incompetence, bicornuate uterus associated rhabdomyosarcoma, 3:55
with, 2:40 undifferentiated endocervical sarcoma, 3:55
Cervical intraepithelial neoplasia, vulvar carcinoma Cervical stenosis, 3:8–11
associated with, 4:62 differential diagnosis, 3:9
Cervical leiomyoma, 3:16–19 hematosalpinx associated with, 6:55
differential diagnosis, 3:17 pyomyoma associated with, 2:63
endocervical polyp vs., 3:13 Cervicitis, chronic: nabothian cysts associated with,
genital lymphoma vs., 7:3 3:69
staging, grading, & classification, 3:18 Cesarean section. See Post cesarean section
Cervical leiomyosarcoma, 3:55 appearance of uterus.
Cervical lymphoma Chlamydia trachomatis infection, salpingitis isthmica
adenoma malignum vs., 3:51 nodosa associated with, 6:31
cervical sarcoma vs., 3:55 CHM (complete hydatidiform mole). See
Cervical melanoma, 3:58–61 Hydatidiform mole, complete.
Cervical metastases. See also Genital metastases. “Chocolate” cyst. See Endometrioma.
cervical sarcoma vs., 3:55 Choriocarcinoma, gestational. See also Gestational
Cervical myoma. See Cervical leiomyoma. trophoblastic disease.
Cervical nabothian cysts, 3:68–71 etiology, 2:150
adenoma malignum vs., 3:51 genetics, 2:150
cervical glandular hyperplasia vs., 3:65 gross pathology and surgical features, 2:151
differential diagnosis, 3:69 image gallery, 2:157–158
Gartner duct cysts vs., 4:83 imaging findings, 2:151, 152
Cervical neoplasms metastatic (images), 2:161
adenocarcinoma. See Cervical adenocarcinoma. microscopic pathology, 2:151
adenoma malignum, 3:50–54 ovarian choriocarcinoma vs., 5:137
cervical glandular hyperplasia associated with, routes of spread, 2:150
3:65 staging (image), 2:147
differential diagnosis, 3:51 Choriocarcinoma, ovarian, 5:136–139
nabothian cysts vs., 3:69 differential diagnosis, 5:137–138
carcinoma. See Cervical carcinoma. ovarian yolk sac tumor vs., 5:133
endocervical polyp, 3:12–15 Chromosome 12q13-15 translocation, aggressive
cervical leiomyoma vs., 3:17 angiomyxoma associated with, 4:77
differential diagnosis, 3:12 Chromosome 46,XX disorders of sexual
endometriosis vs., 5:2–1 development, ambiguous genitalia associated
history of, vulvar carcinoma associated with, 4:62 with, 7:18
leiomyoma. See Cervical leiomyoma. Chromosome 46,XY disorders of sexual
malignant development
cervical leiomyoma vs., 3:17 ambiguous genitalia associated with, 7:18
endocervical polyp vs., 3:13 dysgerminoma associated with, 5:129
melanoma, 3:58–61 Chronic anovulation, endometrial carcinoma
recurrent tumor, post-trachelectomy appearance associated with, 2:128
vs., 3:63 Chronic cervicitis, endocervical polyp associated
sarcoma, 3:54–57 with, 3:13
with histology other than adenoma malignum, Cirsoid aneurysm. See Uterine arteriovenous
adenoma malignum vs., 3:51 malformation.
Cervical polyp. See Endocervical polyp. Clear cell adenocarcinoma, cervical
Cervical post-trachelectomy appearance, 3:62–63 general features, 3:29
Cervical sarcoma, 3:54–57 microscopic pathology, 3:30
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Clear cell carcinoma mucinous cystadenoma vs., 5:69
INDEX
ovarian, 5:98–103 serous cystadenoma vs., 5:63

differential diagnosis, 5:99–100 Corpus luteum, hemorrhagic: acute adnexal torsion
ovarian endometrioid carcinoma vs., 5:93 vs., 5:237
staging, grading, & classification, 5:100 Cortical inclusion cyst. See Ovarian inclusion cyst.
vaginal, yolk sac tumor vs., 4:51 Costello syndrome, vaginal embryonal
Coccygeus muscle rhabdomyosarcoma associated with, 4:47
anatomy (graphic), 8:12 Cryosurgery, cervical stenosis associated with, 3:9
anatomy and function, 8:3 Cryptorchidism, ambiguous genitalia vs., 7:18
axial oblique T2WI MR, 8:12 CT technique and anatomy, 1:18–21. See also PET/
Collagen injections, periurethral: Gartner duct cysts CT technique and imaging issues.
vs., 4:84 Cystadenocarcinoma, ovarian. See Mucinous
Collagen vascular disease causing multiple cystadenocarcinoma, ovarian.
pulmonary nodules, benign metastasizing Cystadenofibroma and adenofibroma, 5:74–79
leiomyoma vs., 2:85 Cystadenoma
Colon cancer, endometriosis vs., 5:2–1 mucinous. See Mucinous cystadenoma, ovarian.
Complete androgen insensitivity syndrome. See serous. See Serous cystadenoma, ovarian.
Androgen insensitivity syndrome. Cystic adenomyosis, uterine, 2:202–205
Complete hydatidiform mole (CHM). See differential diagnosis, 2:203
Hydatidiform mole, complete. unicornuate uterus vs., 2:27
Complex duplication anomalies Cystic adnexal mass, cervical
bicornuate uterus vs., 2:39 degenerated leiomyoma vs., 2:74
uterus didelphys vs., 2:33 nabothian cysts vs., 3:69
Computed tomography. See CT technique and Cystic corpus luteum. See Corpus luteal cyst.
anatomy; PET/CT technique and imaging Cystic glandular hypertrophy, adenomyosis vs.,
issues. 2:104
Congenital anomalies Cystic ovarian teratoma
anorectal. See Anorectal congenital anomalies. benign, lipomatous uterine tumors vs., 2:97
cervical, cervical stenosis vs., 3:9 mucinous cystadenoma vs., 5:69
uterine. See Uterus, congenital anomalies. Cystocele
vaginal. See Vaginal congenital anomalies. clinical findings related to pelvic organ prolapse,
Constipation. See also Obstructed defecation, 8:70
imaging. image interpretation, 8:81
classification based on etiology and site types and classification, 8:68
(graphic), 8:115 urethral diverticulum vs., 4:96
clinical evaluation, 8:89 uterine, grading of, 8:82
major types, 8:112 Cystocolpoproctography, dynamic contrast, 8:82
D
pathophysiology, 8:112
Contraceptive device evaluation, 2:180–187
Conventional evacuation proctography
(“defecography”), 8:91–92
anterior rectal wall mucosal prolapse, 8:123 Defecation, obstructed. See Obstructed defecation,
fecal incontinence imaging, 8:110–111 imaging.
findings in normal subjects, 8:92 Defecography. See Conventional evacuation
image analysis, 8:91 proctography (“defecography”); MR
image findings, 8:102 defecography.
images, 8:100 Degenerated uterine leiomyoma, 2:72–79
indications, 8:91 benign, lipomatous uterine tumors vs., 2:97
limitations, 8:92 differential diagnosis, 2:74
rectocele appearance, 8:118 endometrial stromal sarcoma vs., 2:143
report template (graphic), 8:116 pyomyoma vs., 2:63
technique, 8:91 sarcomatous, lipomatous uterine tumors vs., 2:97
Corpus luteal cyst, 5:18–23 Dermoid (mature teratoma), ovarian, 5:114–123
acute adnexal torsion associated with, 5:238 acute adnexal torsion associated with, 5:238
differential diagnosis, 5:20 cystic
follicular cyst vs., 5:14 immature teratoma vs., 5:125
hemorrhagic ovarian cyst associated with, 5:30
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malignant transformation, ovarian carcinoid differential diagnosis, 2:95
INDEX
vs., 5:141 intravenous leiomyomatosis vs., 2:91
differential diagnosis, 5:116 Distal paraurethral gland cyst. See Skene’s gland cyst.
dysgerminoma vs., 5:129 Diverticulitis, pelvic inflammatory disease vs., 6:8
endometrioma vs., 5:191 Diverticulum, uterine. See Post cesarean section
fibroma, thecoma, and fibrothecoma vs., 5:161 appearance of uterus.
follicular cyst vs., 5:14 DNA mismatch repair defects, endometrial
hemorrhagic ovarian cyst vs., 5:29 carcinoma associated with, 2:128
natural history and prognosis, 5:117 Dominant follicle. See Follicular cyst.
ovarian transitional cell carcinoma vs., 5:109 Dorsal urethral ligaments
ovarian yolk sac tumor vs., 5:133 MR imaging, 8:62
pathology, 5:116 suburethral ligament, 8:41
ruptured, pelvic inflammatory disease vs., 6:8 terminology, 8:41
serous cystadenoma vs., 5:63 Duplicated inferior vena cava thrombosis, ovarian
solid, immature teratoma vs., 5:125 vein thrombosis vs., 5:228
struma ovarii vs., 5:150 Dynamic and static phased-array MR, 8:89–90
DES (diethylstilbestrol) exposure, 2:50–51 dimensions of anal sphincter complex, 8:90
differential diagnosis, 2:51 imaging of fecal incontinence, 8:103
in utero, risk factor for cervical carcinoma, 3:29 imaging planes and field of view, 8:89
müllerian duct anomalies associated with, 2:18 MR appearance of anal sphincter complex,
uterine hypoplasia/agenesis vs., 2:21 8:89–90
Descending perineum syndrome technique, 8:89
fecal incontinence associated with, 8:102 topographic MR anatomy, 8:90
image findings, 8:113 Dynamic contrast cystocolpoproctography, 8:82
MR imaging, 8:124 Dysgenetic gonads, dysgerminoma associated with,
rectal evacuation abnormalities associated with, 5:129
8:112 Dysgerminoma, 5:128–131
Desmoid tumor, endometriosis vs., 5:201 differential diagnosis, 5:129
Developing ovarian follicle, ovarian inclusion cyst ovarian choriocarcinoma vs., 5:137
vs., 5:35 ovarian mixed germ cell tumor, embryonal
Diabetes mellitus, endometrial carcinoma associated carcinoma and polyembryoma vs., 5:145
with, 2:128 ovarian yolk sac tumor vs., 5:133
DICER1 gene mutation, Sertoli-stromal cell tumors staging, grading, & classification, 5:129
associated with, 5:167–168 Dyskinetic puborectalis muscle
Didelphys uterus. See Uterus didelphys. image findings, 8:114
Diethylstilbestrol (DES) exposure. See DES MR imaging, 8:125
(diethylstilbestrol) exposure. rectal evacuation abnormalities associated with,
Diffuse myometrial hypertrophy, adenomyosis vs., 8:113
E
2:104
Diffuse uterine leiomyomatosis, 2:86–89
benign metastasizing leiomyoma associated with,
2:85
differential diagnosis, 2:87 Ectopic pregnancy
intravenous leiomyomatosis vs., 2:91 acute adnexal torsion vs., 5:238
peritoneal, benign metastasizing leiomyoma corpus luteal cyst vs., 5:20
associated with, 2:85 hematosalpinx associated with, 6:55
Diploid karyotype hemorrhagic ovarian cyst vs., 5:29
complete hydatidiform mole associated with, ovarian choriocarcinoma vs., 5:137
2:150 pyosalpinx vs., 6:15
gestational trophoblastic disease associated with, tubal, paratubal cyst vs., 6:3
2:150 Ectopic ureterocele, Gartner duct cysts vs., 4:83
invasive hydatidiform mole associated with, Edema, ovarian, massive. See Massive ovarian edema
2:150 and fibromatosis.
Disorders of sexual development. See Ambiguous Edematous fibroma, massive ovarian edema and
genitalia; Gonadal dysgenesis. fibromatosis vs., 5:243
Disseminated peritoneal leiomyomatosis, 2:94–95 EGFR gene, malignant mixed mesodermal tumor
benign metastasizing leiomyoma associated with, associated with, 2:116
2:85
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Electromyography, for anorectal dysfunction, 8:89 staging
INDEX
Embryonal carcinoma, ovarian. See Ovarian mixed AJCC Stages/Prognostic Groups, 2:125
germ cell tumor, embryonal carcinoma and (T), 2:124
polyembryoma. (N), 2:124
Embryonal rhabdomyosarcoma. See Vaginal (M), 2:124
embryonal rhabdomyosarcoma. imaging findings, 2:130–131
Endoanal MR metastases, organ frequency, 2:127
imaging of fecal incontinence, 8:103 N1, 2:127
posterior pelvic floor compartment, 8:91 N2, 2:127
Endoanal ultrasound reporting checklist, 2:133
fecal incontinence, 8:103 restaging, 2:131
posterior pelvic floor compartment, 8:92 stage IA-IB (T1a-T1b N0 M0), 2:126
Endocervical gland cysts. See Nabothian cysts, stage II (T2 N0 M0), 2:126
cervical. stage IIIA-B (T3a-T3b N0 M0), 2:126
Endocervical glandular hyperplasia. See Cervical stage IVA (T4 N0 M0), 2:126
glandular hyperplasia. treatment options by stage, 2:132–133
Endocervical polyp, 3:12–15 staging (images), 2:134–141
cervical leiomyoma vs., 3:17 recurrence, 2:141
differential diagnosis, 3:12 stage IA (T1a N0 M0), 2:134–135
Endocrine carcinoma. See Merkel cell tumor, vulvar. stage IB (T1b N0 M0), 2:136–137
Endodermal sinus tumor. See Ovarian yolk sac tumor. stage II (T2 N0 M0), 2:138
Endometrial abnormalities stage II (T3 N0 M0), 2:139
tamoxifen-induced changes associated with, 2:176 stage IIIC1 (T3 N1 M0), 2:139
unrelated to tamoxifen, tamoxifen-induced stage IVA (T4 N0 M0), 2:139–140
changes vs., 2:175 stage IVA (T4 N1 M0), 2:140
Endometrial atrophy, 2:14–15 stage IVB (T3 N1 M1), 2:141
Endometrial blood clot: Asherman syndrome, stage IVB (T3a N1 M1), 2:141
endometrial synechiae vs., 2:55 stage IVB (T4 N1 M1), 2:141
Endometrial carcinoma, 2:124–141 uterine arteriovenous malformation vs., 2:164
adenomyosis associated with, 2:194 uterine artery embolization vs., 2:170
adenosarcoma vs., 2:111 Endometrial cavity, gas in: endometritis vs., 2:59
classification, 2:128 Endometrial hyperplasia, 2:106–109
clinical issues, 2:132–133 associated abnormalities, 2:108
natural history and prognosis, 2:132–133 cystic, endometrial atrophy vs., 2:15
presentation, 2:132 differential diagnosis, 2:107
treatment options, 2:132–133 disseminated peritoneal leiomyomatosis
treatment options by stage, 2:132–133 associated with, 2:95
endometrial hyperplasia vs., 2:107 focal, endometrial polyps vs., 2:101
endometrial polyps vs., 2:101 ovarian endometrioid carcinoma associated with,
endometrial stromal sarcoma vs., 2:143 5:94
genital lymphoma vs., 7:3 sclerosing stromal tumor associated with, 5:174
image gallery, 2:134–141 staging, grading, & classification, 2:108
imaging findings, 2:129–131 Endometrial infection. See Endometritis.
detection, 2:129–130 Endometrial neoplasms
restaging, 2:131 endometrial hyperplasia associated with, 2:108
staging, 2:130–131 uterine leiomyosarcoma vs., 2:121
malignant mixed mesodermal tumor vs., 2:116 Endometrial polyps, 2:100–105
overview, 2:128 adenomyoma vs., 2:200
pathology, 2:128–129 adenomyosis associated with, 2:194
epidemiology and cancer incidence, 2:128–129 adenosarcoma associated with, 2:111
general features, 2:128–129 Asherman syndrome, endometrial synechiae vs.,
genetics, 2:128 2:55
histopathologic types, 2:129 cystic, endometrial atrophy vs., 2:15
microscopic pathology, 2:129 differential diagnosis, 2:101
routes of spread, 2:128 endocervical polyp vs., 3:13
types of endometrial cancer, 2:128 endometrial hyperplasia associated with, 2:108
reporting checklist, 2:133 endometrial hyperplasia vs., 2:107
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Endometrial sinus tumor. See Vaginal yolk sac Endometriosis interna. See Adenomyosis, uterine.
INDEX
tumor. Endometriotic cyst. See Endometrioma.
Endometrial stromal nodule, benign: endometrial Endometritis, 2:58–61
stromal sarcoma vs., 2:143 differential diagnosis, 2:59
Endometrial stromal sarcoma, 2:142–145 endometrial hyperplasia vs., 2:107
differential diagnosis, 2:143 pyomyoma vs., 2:63
epithelioid endometrial, endocervical polyp vs., Endometrium
3:13 imaging anatomy, 2:3
low-grade, adenomyosis vs., 2:104 secretory, endometrial hyperplasia vs., 2:107
malignant mixed mesodermal tumor vs., 2:116 ultrasound
staging, grading, & classification, 2:144 cyclical appearance, 2:8
Endometrial synechiae. See Asherman syndrome, normal endometrium, 2:9
endometrial synechiae. Endopelvic fascia, anterior pelvic compartment
Endometrial thickening, thecoma associated with, anatomy and function, 8:41
5:162 MR imaging, 8:62
Endometrial trauma: Asherman syndrome, Endopelvic fascia, middle pelvic compartment,
endometrial synechiae associated with, 2:55 image interpretation, 8:81
Endometrioid adenocarcinoma, cervical, 3:30 Endopelvic fascia, pelvic floor
Endometrioid carcinoma, ovarian, 5:92–97 anatomy and functional correlation, 8:5
differential diagnosis, 5:93 axial oblique T2WI TSE MR, 8:11
ovarian clear cell carcinoma vs., 5:99 graphic, 8:10–11
staging, grading, & classification, 5:94 pelvic floor muscle and endopelvic fascial
Endometrioma, 5:188–197 interaction, 8:5
corpus luteal cyst vs., 5:20 Endopelvic fascial defect
differential diagnosis, 5:191 anterior pelvic compartment, 8:62
follicular cyst vs., 5:14 stress urinary incontinence associated with
genetics, 5:191 (images), 8:135
hemorrhagic ovarian cyst vs., 5:29 Enterocele
mucinous cystadenoma vs., 5:69 clinical findings related to pelvic organ prolapse,
ovarian clear cell carcinoma vs., 5:99 8:70
ovarian dermoid (mature teratoma) vs., 5:116 fecal incontinence associated with, 8:102
ovarian endometrioid carcinoma vs., 5:93 image interpretation, 8:81
serous cystadenoma vs., 5:63 Entrapped ovarian cyst/syndrome. See Peritoneal
urethral diverticulum vs., 4:96 inclusion cysts.
Endometriosis, 5:198–207 Epidermal growth factor receptor, vulvar carcinoma
adenomyosis associated with, 2:194 associated with, 4:62
cervical glandular hyperplasia vs., 3:65 Epidermal inclusion cyst
cervical stenosis associated with, 3:9 Bartholin cysts vs., 4:87
differential diagnosis, 5:201 bartholinitis vs., 4:91
disseminated peritoneal leiomyomatosis Skene’s gland cyst vs., 4:99
associated with, 2:95 Epithelial inclusion cyst. See Ovarian inclusion cyst.
extraovarian, endometrioma associated with, Epithelial ovarian neoplasms. See Ovarian
5:191 neoplasms, epithelial.
genetics, 5:201 Epithelial tumor, surface
hematosalpinx associated with, 6:55 corpus luteal cyst vs., 5:20
hemorrhagic, tubo-ovarian abscess vs., 6:19–20 follicular cyst vs., 5:14
hydrosalpinx associated with, 6:12 ERBB2 (HER-2/neu) gene
ovarian carcinoma variants associated with, 5:47 malignant mixed mesodermal tumor associated
ovarian endometrioid carcinoma associated with, with, 2:116
5:94, 100 overexpression, endometrial carcinoma
staging, grading, & classification, 5:201 associated with, 2:128
subserosal, adenomyoma vs., 2:200 Estrogen replacement therapy
tubal, salpingitis isthmica nodosa vs., 6:31 endometrial carcinoma associated with, 2:128
uterus didelphys associated with, 2:33 endometrial polyps associated with, 2:101
vulvar hemangioma vs., 4:25 exogenous, malignant mixed mesodermal tumor
Endometriosis-associated malignancy, associated with, 2:116
endometrioma associated with, 5:191 ovarian carcinoma associated with, 5:47
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progestogenic therapy, nabothian cysts (M), 6:38
INDEX
associated with, 3:70 imaging findings, 6:45

unopposed estrogen stimulation, endometrial metastases, organ frequency, 6:43
hyperplasia associated with, 2:107 nodal drainage, 6:43
vulvar leiomyosarcoma associated with, 4:71 reporting checklist, 6:46
Estrogen-secreting ovarian tumors, endometrial restaging (imaging findings), 6:45
hyperplasia associated with, 2:108 T1a (FIGO IA), 6:39, 41
Estrogen secretion, endocervical polyp associated T1b (FIGO IB), 6:41
with, 3:13 T1c (FIGO IC), 6:40, 41
Estrogenic manifestations, granulosa cell tumor T2a (FIGO IIA), 6:40, 41
associated with, 5:155 T2b (FIGO IIB), 6:42
Evacuation proctography (“defecography”), T2c (FIGO IIC), 6:42
conventional. See Conventional evacuation T3 (FIGO III), 6:40
proctography (“defecography”). T3a (FIGO IIIA), 6:42
Ewing sarcoma, cervical, 3:55 T3b (FIGO IIIB), 6:42
External anal sphincter. See also Anal sphincter T3c (FIGO IIIC), 6:43
complex. Tis, 6:39
abnormalities staging (images), 6:47–53
MR, 8:107–109 stage IA (T1a N0 M0), 6:47–49
ultrasound, 8:111 stage IIA (T2a N0 M0), 6:49–50
anatomy, 8:88 stage IIC (T2c N0 M0), 6:50–51
atrophy, image findings, 8:103 stage IIIC (T2a N1 M0), 6:51–52
defects and scar tissue, image findings, 8:102–103 stage IIIC (T2b N1 M0), 6:53
structural abnormalities (graphic), 8:106 Fallopian tubes, 6:2–55
External urethral sphincter (graphics), 8:45 anatomic relationship to uterus, 2:2–3
F
hematosalpinx, 6:54–55
pyosalpinx vs., 6:15
inflammation/infection. See Fallopian tubes,
Fallopian tube adenocarcinoma, tubal leiomyoma inflammation/infection.
vs., 6:35 neoplasms. See Fallopian tubes, neoplasms.
Fallopian tube carcinoma, 6:38–53 paratubal cyst. See Paratubal cyst.
classification, 6:44 ultrasound, anatomy, 2:9
clinical issues, 6:45–46 Fallopian tubes, inflammation/infection
natural history and prognosis, 6:46 actinomycosis, 6:26–29
presentation, 6:45–46 differential diagnosis, 6:27
treatment options, 6:46 genital tuberculosis vs., 6:24
hematosalpinx associated with, 6:55 genital tuberculosis, 6:22–25
image gallery, 6:47–53 actinomycosis of fallopian tubes vs., 6:27
imaging findings, 6:44–45 differential diagnosis, 6:24
detection, 6:44–45 hydrosalpinx. See Hydrosalpinx.
restaging, 6:45 pelvic inflammatory disease. See Pelvic
staging, 6:45 inflammatory disease.
pathology, 6:44 pyosalpinx. See Pyosalpinx.
associated abnormalities, 6:44 salpingitis isthmica nodosa, 6:30–33
epidemiology & cancer incidence, 6:44 tubo-ovarian abscess. See Tubo-ovarian abscess.
etiology, 6:44 Fallopian tubes, neoplasms
genetics, 6:44 adenocarcinoma, tubal leiomyoma vs., 6:35
gross pathology and surgical features, 6:44 carcinoma. See Fallopian tube carcinoma.
microscopic pathology, 6:44 leiomyoma, 6:34–37
routes of spread, 6:44 malignant, hydrosalpinx associated with, 6:12
primary, hydrosalpinx vs., 6:11 other mesodermal tubal tumors, tubal
reporting checklist, 6:46 leiomyoma vs., 6:35
staging Fecal incontinence
AJCC Stages/Prognostic Groups, 6:38 clinical evaluation, 8:88–89
(T), 6:38 etiology, 8:102
(N), 6:38
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Fecal incontinence, imaging, 8:102–111 ovarian inclusion cyst vs., 5:35
INDEX
anal sphincter abnormalities (graphic), 8:106 peritoneal inclusion cysts vs., 5:220
choice of imaging technique serous cystadenoma vs., 5:63
endoanal MR vs. endoanal ultrasound, 8:103 Foreign bodies
phased-array vs. endoanal MR, 8:103 endocervical polyp associated with, 3:13
continence mechanisms and etiologies of vaginal, 4:102–109
incontinence (graphic), 8:105 Functional cyst. See Corpus luteal cyst; Follicular cyst.
G
conventional evacuation proctography
(“defecography”), 8:91–92, 110–111
external anal sphincter abnormalities on MR,
8:107–109
imaging findings, 8:102–103 Gartner duct cysts, 4:82–85
anal sphincter atrophy, 18:103 Bartholin cysts vs., 4:87
anal sphincter defects and scar tissue, 8:102– Bartholin gland carcinoma vs., 4:55
103 bartholinitis vs., 4:91
defecographic, 8:102 differential diagnosis, 4:83–84
pitfalls, 18:103 Skene’s gland cyst vs., 4:99
internal anal sphincter abnormalities on MR, urethral diverticulum vs., 4:95
8:107–109 Gas in endometrial cavity, endometritis vs., 2:59
normal anatomy and evacuation mechanisms Genital lymphoma, 7:2–7
(graphics), 8:104 differential diagnosis, 7:3
sphincter abnormalities on ultrasound, 8:111 genetics, 7:3
Female genital tuberculosis. See Genital tuberculosis. staging, grading, & classification, 7:3–4
Fibrial cyst. See Paratubal cyst. Genital metastases, 7:8–13
Fibroids. See Uterine leiomyoma. Genital muscles, superficial external, anatomy and
degenerated. See Degenerated uterine leiomyoma. functional correlation, 8:6
parasitic. See Parasitic uterine leiomyoma. Genital tuberculosis, 6:22–25
Fibroma, cervical. See Cervical leiomyoma. actinomycosis of fallopian tubes vs., 6:27
Fibroma, thecoma, and fibrothecoma, ovarian, differential diagnosis, 6:24
5:160–166 Germ cell neoplasms. See Ovarian neoplasms, germ
differential diagnosis, 5:161 cell.
edematous fibroma, massive ovarian edema and Germinal inclusion cyst. See Ovarian inclusion cyst.
fibromatosis vs., 5:243 Gestational trophoblastic disease, 2:146–161
endometrioma vs., 5:191 classification, 2:150
granulosa cell tumor vs., 5:155 clinical issues, 2:152–153
ovarian transitional cell carcinoma vs., 5:109– natural history and prognosis, 2:153
110 presentation, 2:152–153
sclerosing stromal tumor vs., 5:173 treatment options, 2:153
Sertoli-stromal cell tumors vs., 5:167 image gallery, 2:154–161
uterine leiomyoma vs., 2:68 choriocarcinoma, 2:157–158
Fibromyolipoma complete hydatidiform mole, 2:154–155
degenerated. See Degenerated uterine leiomyoma. early, 2:154
subtype of lipomatous uterine tumors, 2:97 late, 2:154
Fibrothecoma. See Fibroma, thecoma, and invasive hydatidiform mole, 2:156
fibrothecoma, ovarian. metastatic choriocarcinoma, 2:161
18-Fluorodeoxyglucose (FDG-18) PET/CT. See PET/ partial hydatidiform mole
CT technique and imaging issues. early, 2:156
Focal adenomyoma, degenerated leiomyoma vs., late, 2:156
2:74 placental-site trophoblastic tumor
Focal adenomyosis, degenerated leiomyoma vs., T1, 2:159
2:74 T2, 2:160
Focal endometrial hyperplasia, endometrial polyps post-treatment arteriovenous fistula, 2:161
vs., 2:101 imaging findings, 2:151–152
Follicular cyst, 5:12–17 detection, 2:151–152
acute adnexal torsion associated with, 5:238 staging, 2:152
differential diagnosis, 5:14 overview, 2:150
mucinous cystadenoma vs., 5:69
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H
pathology, 2:150–151
INDEX
associated diseases, abnormalities, 2:150

epidemiology and cancer incidence, 2:150
etiology, 2:150 Heart thrombus, right-sided, in transit: intravenous
general features, 2:150 leiomyomatosis vs., 2:91
genetics, 2:150 Hemangioma
gross pathology and surgical features, cavernous. See Uterine arteriovenous
2:150–151 malformation.
microscopic pathology, 2:151 uterine, arteriovenous malformation vs., 2:164
routes of spread, 2:150 vaginal, paraganglioma vs., 4:29
reporting checklist, 2:153 vulvar, 4:24–27
staging Hemangiopericytoma, aggressive angiomyxoma vs.,
AJCC Stages/Prognostic Groups, 2:146 4:77
(T), 2:146 Hematometra, endometrial polyps vs., 2:101
(N), 2:146 Hematosalpinx, 6:54–55
(M), 2:146 differential diagnosis, 6:55
choriocarcinoma, 2:147 pyosalpinx vs., 6:15
complete hydatidiform mole, 2:147 Hemorrhagic corpus luteum, acute adnexal torsion
imaging findings, 2:152 vs., 5:237
metastases, organ frequency, 2:149 Hemorrhagic cyst, massive ovarian edema and
partial hydatidiform mole, 2:147 fibromatosis vs., 5:243
placental-site trophoblastic tumor, 2:147 Hemorrhagic degeneration of leiomyoma,
reporting checklist, 2:153 unicornuate uterus vs., 2:27
T1, 2:148 Hemorrhagic ovarian cyst, 5:28–33
T2, 2:148–149 differential diagnosis, 5:29–30
uterine arteriovenous malformation vs., 2:164 endometrioma vs., 5:191
Gestational trophoblastic neoplasia granulosa cell tumor vs., 5:155
presentation, 2:152–153 ovarian dermoid (mature teratoma) vs., 5:116
theca lutein cysts associated with, 5:26 tubo-ovarian abscess vs., 6:19–20
treatment options, 2:153 HER-2/neu, vulvar carcinoma associated with, 4:62
types, 2:150 Herlyn-Werner-Wunderlich syndrome, uterus
Glandular hyperplasia, cervical, 3:64–67 didelphys associated with, 2:33
differential diagnosis, 3:65 High coital frequency
with gastric metaplasia, adenoma malignum vs., pyosalpinx associated with, 6:16
3:51 tubo-ovarian abscess associated with, 6:20
Gonadal dysgenesis, 7:20–23. See also Sexual Hirsutism, thecoma associated with, 5:162
development, abnormal. HIV infection, genital lymphoma associated with,
androgen insensitivity syndrome vs., 7:15 7:3
differential diagnosis, 7:21–22 HMG2 gene, aggressive angiomyxoma associated
genetics, 7:22 with, 4:77
uterine hypoplasia/agenesis vs., 2:21 Hormonal disturbances, cystic adenomyosis
Gonadal vein thrombosis. See Ovarian vein associated with, 2:204
thrombosis. Hormone replacement therapy. See Estrogen
Gorlin-Goltz syndrome, fibroma, thecoma, and replacement therapy.
fibrothecoma associated with, 5:161 HPV-encoded oncoproteins E6 and E7, vulvar
Granulosa cell tumor, 5:154–159 carcinoma associated with, 4:62
differential diagnosis, 5:155 Human papillomavirus
disseminated peritoneal leiomyomatosis risk factor for cervical carcinoma, 3:29
associated with, 2:95 vulvar carcinoma associated with, 4:62–63
mucinous cystadenoma associated with, 5:70 Hydatid cyst of Morgagni. See Paratubal cyst.
ovarian carcinoid vs., 5:141 Hydatidiform mole, complete. See also Gestational
Sertoli-stromal cell tumors vs., 5:167 trophoblastic disease.
staging, grading, & classification, 5:155 gross pathology and surgical features, 2:150
Greater vestibular gland cyst. See Bartholin cysts. image gallery, 2:154–155
Greater vestibular gland infection/abscess. See early, 2:154
Bartholinitis. late, 2:154
Gynecologic procedures, vaginal fistula associated imaging findings, 2:151, 152
with, 4:112
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I
microscopic pathology, 2:151
INDEX
natural history and prognosis, 2:153
presentation, 2:152
routes of spread, 2:150
staging (image), 2:147
classifying vaginal support system defects, 8:81
treatment options, 2:153
image interpretation, 8:81
Hydatidiform mole, invasive. See also Gestational
MR anatomy, 8:4, 23–25
trophoblastic disease.
Immature teratoma, 5:124–127
gross pathology and surgical features, 2:150
image gallery, 2:156
ovarian dermoid (mature teratoma) vs., 5:116
imaging findings, 2:151, 152
staging, grading, & classification, 5:126
Immunodeficiency syndromes, vulvar carcinoma
associated with, 4:62
Hydatidiform mole, partial. See also Gestational
Immunosuppression, risk factor for cervical
trophoblastic disease.
carcinoma, 3:29
genetics, 2:150
Imperforate hymen, 4:14–15
gross pathology and surgical features, 2:150
image gallery, 2:156
Gartner duct cysts vs., 4:84
imaging findings, 2:151, 152
vaginal atresia vs., 4:11
vaginal septa vs., 4:17
natural history and prognosis, 2:153
Inclusion cysts
presentation, 2:152
epidermal. See Epidermal inclusion cyst.
ovarian, 5:34–39
staging (image), 2:147
peritoneal. See Peritoneal inclusion cysts.
treatment options, 2:153
Infected leiomyoma. See Pyomyoma.
Hydrometrocolpos, vaginal embryonal
Infection. See Inflammation/infection.
rhabdomyosarcoma vs., 4:47
Infectious diseases causing multiple pulmonary
Hydrosalpinx, 6:10–13
nodules, benign metastasizing leiomyoma vs.,
differential diagnosis, 6:11–12
2:85
ovarian hyperstimulation syndrome vs., 5:209
Infectious process, cervical glandular hyperplasia
ovarian vein thrombosis vs., 5:228
vs., 3:65
paratubal cyst vs., 6:3
Inferior vena cava, duplicated, thrombosis of,
pelvic congestion syndrome vs., 5:233
ovarian vein thrombosis vs., 5:228
peritoneal inclusion cysts vs., 5:220
Inflammation/infection
pyosalpinx vs., 6:15
cervical stenosis associated with, 3:9
Hydroureter, ovarian vein thrombosis vs., 5:228
fallopian tubes. See Fallopian tubes,
Hymenal obstruction. See Imperforate hymen.
inflammation/infection.
Hyperreactio luteinalis. See Theca lutein cysts.
pyosalpinx associated with, 6:16
Hypertension
Skene’s gland cyst associated with, 4:100
endometrial carcinoma associated with, 2:128
tubo-ovarian abscess associated with, 6:20
polycystic ovary syndrome associated with, 5:214
uterus. See Uterus, inflammation/infection.
Hypogonadotropic hypogonadism, gonadal
vaginal fistula associated with, 4:112
dysgenesis vs., 7:22
Inflammatory cysts of pelvic peritoneum. See
Hysterectomy
Peritoneal inclusion cysts.
benign metastasizing leiomyoma associated with,
Inflammatory diseases causing multiple pulmonary
2:85
nodules, benign metastasizing leiomyoma vs.,
laparoscopic, parasitic leiomyoma associated
2:85
with, 2:82
Infundibulum, fallopian tubes, anatomic
total, uterine hypoplasia/agenesis vs., 2:21
relationship, 2:3
without salpingo-oophorectomy, hydrosalpinx
Insulin resistance, polycystic ovary syndrome
Hysterosalpingography, 1:8–15
Internal anal sphincter. See also Anal sphincter
procedure, 1:8–11
complex.
uterine anatomy (image), 2:9
abnormalities
in patients with obstructed defecation, rectal
evacuation abnormalities associated with,
8:113
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MR, 8:107–109 ovarian carcinosarcoma vs., 5:105
INDEX
ultrasound, 8:111 ovarian transitional cell carcinoma vs., 5:110

anatomy, 8:88 sclerosing stromal tumor vs., 5:173
L
atrophy, image findings, 8:103
defects and scar tissue, image findings, 8:102–103
structural abnormalities (graphic), 8:106
Intersex conditions. See Ambiguous genitalia;
Gonadal dysgenesis. Labial adhesions, imperforate hymen vs., 4:15
Intrauterine adhesions. See Asherman syndrome, Laser therapy, cervical stenosis associated with, 3:9
endometrial synechiae. Lateral pelvic wall anatomy
Intrauterine clot and debris, endometritis vs., 2:59 graphic, 8:9
Intrauterine contraceptive device (IUCD) sagittal T1WI MR, 8:9
contraceptive device evaluation, 2:180–187 Leiomyoma
pyosalpinx associated with, 6:16 cervical, 3:16–19
tubo-ovarian abscess associated with, 6:20 differential diagnosis, 3:17
Intrauterine device (IUD) endocervical polyp vs., 3:13
chronic irritation due to, cystic adenomyosis genital lymphoma vs., 7:3
associated with, 2:204 staging, grading, & classification, 3:18
contraceptive device evaluation, 2:180–187 tubal, 6:34–37
hematosalpinx associated with, 6:55 uterine. See Uterine leiomyoma.
pelvic inflammatory disease associated with, 6:8 vaginal. See Vaginal leiomyoma.
Intravenous uterine leiomyomatosis, 2:90–93 Leiomyoma/fibroma, ovarian: tubal leiomyoma vs.,
benign metastasizing leiomyoma associated with, 6:35
2:85 Leiomyomatosis, diffuse uterine, 2:86–89
differential diagnosis, 2:91 benign metastasizing leiomyoma associated with,
disseminated peritoneal leiomyomatosis vs., 2:95 2:85
endometrial stromal sarcoma vs., 2:143 differential diagnosis, 2:87
Intussusception and rectal prolapse intravenous leiomyomatosis vs., 2:91
fecal incontinence associated with, 8:102 peritoneal, benign metastasizing leiomyoma
graphics, 8:120 associated with, 2:85
image findings, 8:113 Leiomyomatosis, disseminated peritoneal, 2:94–95
MR imaging, 8:121–122 benign metastasizing leiomyoma associated with,
rectal evacuation abnormalities associated with, 2:85
8:112–113 differential diagnosis, 2:95
rectal prolapse due to sphincter deficiency and intravenous leiomyomatosis vs., 2:91
level I fascial defect (images), 8:137 Leiomyomatosis, intravenous uterine, 2:90–93
Invasive hydatidiform mole. See Hydatidiform mole, benign metastasizing leiomyoma associated with,
invasive. 2:85
Isthmocele. See Post cesarean section appearance of differential diagnosis, 2:91
uterus. disseminated peritoneal leiomyomatosis vs., 2:95
Isthmus, fallopian tubes: anatomic relationship, 2:3 endometrial stromal sarcoma vs., 2:143
IUCD (intrauterine contraceptive device). See Leiomyosarcoma
Intrauterine contraceptive device (IUCD). cervical, 3:55
IUD. See Intrauterine contraceptive device (IUCD). genital lymphoma vs., 7:3
K
uterine. See Uterine leiomyosarcoma.
vaginal, 4:44–45
vaginal leiomyoma vs., 4:19
KIT gene, malignant mixed mesodermal tumor vulvar, 4:70–71
associated with, 2:116 Levator ani muscle
KRAS gene mutation, endometrial carcinoma anatomy (graphic), 8:13
associated with, 2:128 axial oblique MR, 8:13, 21
Krukenberg tumor components, 8:3
definition, 5:177 functional correlation, 8:3
ovarian carcinoid vs., 5:141 innervation, 8:3
Levator plate, MR anatomy, 8:4
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Levonorgestrel-releasing intrauterine system. See Lynch syndrome
INDEX
Contraceptive device evaluation. endometrial carcinoma associated with, 2:128
Li-Fraumeni syndrome, vaginal embryonal ovarian endometrioid carcinoma associated with,
rhabdomyosarcoma associated with, 4:47 5:94
M
Lipoleiomyoma
pedunculated, ovarian dermoid (mature
teratoma) vs., 5:116
subtype of lipomatous uterine tumors, 2:97
Lipoma Major vestibular gland cyst. See Bartholin cysts.
benign pelvic, lipomatous uterine tumors vs., Major vestibular gland infection/abscess. See
2:97 Bartholinitis.
subtype of lipomatous uterine tumors, 2:97 Malignant mixed carcinosarcoma, cervical, 3:55, 56
Lipomatous ovarian tumor, nonteratomatous: Malignant mixed mesodermal tumor, ovarian.
lipomatous uterine tumors vs., 2:97 See Ovarian carcinosarcoma (ovarian mixed
Lipomatous uterine tumors, 2:96–99 müllerian tumor).
differential diagnosis, 2:97–98 Malignant mixed mesodermal tumor, uterine,
subtypes, 2:97 2:114–119
Liposarcoma adenosarcoma vs., 2:111
pelvic, lipomatous uterine tumors vs., 2:97 differential diagnosis, 2:116
undifferentiated endocervical sarcoma, 3:55, 56 genetics, 2:116
Liver metastases, distant: malignant mixed lipomatous uterine tumors vs., 2:97
mesodermal tumor associated with, 2:116 staging, grading, & classification, 2:116
LNG-IUS (levonorgestrel-releasing intrauterine Malignant peripheral nerve sheath tumor, cervical,
system). See Contraceptive device evaluation. 3:55
Loculated ascites, peritoneal inclusion cysts vs., Malignant serous tumors, serous cystadenoma vs.,
5:220 5:63
Loop electrocautery excision, cervical stenosis Malignant uterine neoplasms. See Uterine
associated with, 3:9 neoplasms.
Low-grade endometrial stromal sarcoma, Marked uterine anteflexion, post cesarean section
adenomyosis vs., 2:104 appearance of uterus vs., 2:190
Low malignant potential serous tumors, serous Massive ovarian edema and fibromatosis, 5:242–247
cystadenoma vs., 5:63 differential diagnosis, 5:243
Low socioeconomic status ovarian choriocarcinoma vs., 5:138
pyosalpinx associated with, 6:16 sclerosing stromal tumor vs., 5:173
risk factor for cervical carcinoma, 3:29 with adnexal torsion, ovarian hyperstimulation
tubo-ovarian abscess associated with, 6:20 syndrome vs., 5:209
Lung metastases, distant: malignant mixed Mature teratoma. See Dermoid (mature teratoma),
mesodermal tumor associated with, 2:116 ovarian.
Luteal cyst. See Corpus luteal cyst. Mayer-Rokitansky-Küster-Hauser syndrome, uterine
Luteoma of pregnancy, theca lutein cysts vs., 5:25 hypoplasia/agenesis associated with, 2:21, 22
Lymphadenopathy Meigs syndrome, fibroma, thecoma, and
necrotic, ovarian vein thrombosis vs., 5:228 fibrothecoma associated with, 5:162
parasitic leiomyoma vs., 2:81 Melanoma
pelvic cervical, 3:58–61
malignant mixed mesodermal tumor vaginal, 4:72–75
associated with, 2:116 vulvar, 4:72–75
pelvic congestion syndrome vs., 5:233 differential diagnosis, 4:73
Lymphocele, paratubal cyst vs., 6:3 Merkel cell tumor vs., 4:81
Lymphoma Melanotic nevus, atypical genital type: vulvar
cervical melanoma vs., 4:73
adenoma malignum vs., 3:51 Menarche, early
cervical sarcoma vs., 3:55 endometrial carcinoma associated with, 2:128
genital, 7:2–7 ovarian carcinoma associated with, 5:47
ovarian, 5:182–187 Menopause, late: endometrial carcinoma associated
differential diagnosis, 5:183 with, 2:128
ovarian metastases vs., 5:177
vaginal, paraganglioma vs., 4:29
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Menstrual cycle patient preparation, 8:32
INDEX
early proliferative phase of cycle, adenomyosis rectocele appearance, 8:119

vs., 2:104 reporting, 8:32
proliferative phase, 2:2 sagittal plane, 8:37, 39
secretory phase, 2:2 MR, dynamic and static phased-array. See Dynamic
Merkel cell tumor, vulvar, 4:80–81 and static phased-array MR.
differential diagnosis, 4:81 MR, endoanal
melanoma vs., 4:73 imaging of fecal incontinence, 8:103
Mesonephric duct remnants, Gartner duct cysts posterior pelvic floor compartment, 8:91
associated with, 4:84 MR technique and anatomy, 1:22–27
Metanephric system abnormalities, Gartner duct MR, urethral, 8:47
cysts associated with, 4:84 MRKH syndrome. See Mayer-Rokitansky-Küster-
Metastases Hauser (MRKH) syndrome.
causing multiple pulmonary nodules, benign Mucinous adenocarcinoma, ovarian: clear cell
metastasizing leiomyoma vs., 2:85 carcinoma vs., 5:99
cervical, cervical sarcoma vs., 3:55 Mucinous cystadenocarcinoma, ovarian, 5:86–91
distant, malignant mixed mesodermal tumor benign
associated with, 2:116 mucinous cystadenocarcinoma vs., 5:87
genital, 7:8–13 ovarian clear cell carcinoma vs., 5:99
ovarian. See Ovarian metastases. differential diagnosis, 5:87
vaginal mucinous cystadenoma vs., 5:69
paraganglioma vs., 4:29 ovarian serous carcinoma vs., 5:81
vaginal melanoma vs., 4:73 staging, grading, & classification, 5:87
vaginal embryonal rhabdomyosarcoma struma ovarii vs., 5:150
associated with, 4:47 Mucinous cystadenoma, ovarian, 5:68–73
vulvar, vulvar melanoma vs., 4:73 choriocarcinoma associated with, 5:138
Metastasizing leiomyoma, benign, 2:84–85 differential diagnosis, 5:69
differential diagnosis, 2:85 dysgerminoma vs., 5:129
intravenous leiomyomatosis vs., 2:91 serous carcinoma vs., 5:81
Metastatic breast cancer, tamoxifen-induced serous cystadenoma vs., 5:63
changes vs., 2:175 struma ovarii vs., 5:150
Metastatic malignant neoplasm, disseminated transitional cell carcinoma associated with, 5:110
peritoneal leiomyomatosis vs., 2:95 Mucinous minimal deviation adenocarcinoma. See
Microsatellite instability, endometrial carcinoma Adenoma malignum, cervical.
associated with, 2:128 Mucinous tumors of ovary, adenoma malignum
Middle compartment of pelvic floor. See Pelvic floor associated with, 3:51
middle compartment imaging; Pelvic floor Mucocele
middle compartment overview. appendiceal
Mixed germ cell tumor, embryonal carcinoma hydrosalpinx vs., 6:11
and polyembryoma. See Ovarian mixed peritoneal inclusion cysts vs., 5:220
germ cell tumor, embryonal carcinoma and mucinous cystadenoma vs., 5:69
polyembryoma. Müllerian adenosarcoma, endocervical polyp vs.,
Mixed müllerian tumor, ovarian. See Ovarian 3:13
carcinosarcoma (ovarian mixed müllerian Müllerian agenesis. See Uterine hypoplasia/agenesis.
tumor). Müllerian agenesis/aplasia, renal anomalies, and
Molar pregnancy, gestational trophoblastic disease cervicothoracic somite deformities (MURCS
associated with, 2:150 syndrome), uterine hypoplasia/agenesis
Mole, hydatidiform. See Hydatidiform mole, associated with, 2:21
complete; Hydatidiform mole, invasive; Müllerian cyst, Gartner duct cysts vs., 4:83
Hydatidiform mole, partial. Müllerian duct anomalies, 2:16–19
Motor-evoked potentials, for anorectal dysfunction, associated abnormalities, 2:18
8:89 class I, uterine hypoplasia/agenesis, 2:21
MR defecography, 8:31–32 class II, unicornuate uterus, 2:27–28
coronal plane, 8:38 class III, uterus didelphys, 2:33
ensuring proper dynamic MR techniques, 8:32 class IV, bicornuate uterus, 2:39
imaging technique, 8:32 class V, septate uterus, 2:43
indications, 8:31 class VI, arcuate uterus, 2:49
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cystic adenomyosis vs., 2:203 Myometrial cyst, post cesarean section appearance
INDEX
embryology, 2:18–19 of uterus vs., 2:190
etiology, 2:18 Myometrial hypertrophy, diffuse: adenomyosis vs.,
hematosalpinx associated with, 6:55 2:104
staging, grading, & classification, 2:18 Myometrium
with hematometrocolpos, Gartner duct cysts vs., anatomy, 2:2
4:84 imaging anatomy, 2:3
N
Müllerian ducts, tubal leiomyoma derived from,
6:35
Müllerian regression deficiency, gonadal dysgenesis
Multicompartmental imaging. See Pelvic floor Nabothian cysts, cervical, 3:68–71
multicompartmental defects, imaging. adenoma malignum vs., 3:51
Multifollicular ovaries, polycystic ovary syndrome cervical glandular hyperplasia vs., 3:65
vs., 5:214 differential diagnosis, 3:69
Multilocular inclusion cyst. See Peritoneal inclusion Gartner duct cysts vs., 4:83
cysts. Necrotic lymphadenopathy, ovarian vein
Multiorgan disorders, 7:2–23 thrombosis vs., 5:228
ambiguous genitalia, 7:16–19 Neuroendocrine tumors, cervical: microscopic
differential diagnosis, 7:18 pathology, 3:30
uterine hypoplasia/agenesis vs., 2:21 Neurofibroma, plexiform: vulvar hemangioma vs.,
androgen insensitivity syndrome, 7:14–15 4:25
differential diagnosis, 7:15 Neurofibromatosis, syndromic: vaginal embryonal
gonadal dysgenesis vs., 7:21 rhabdomyosarcoma associated with, 4:47
uterine hypoplasia/agenesis vs., 2:21 Neurological damage, fecal incontinence associated
genital lymphoma, 7:2–7 with, 8:102
genital metastases, 7:8–13 Niche. See Post cesarean section appearance of
gonadal dysgenesis, 7:20–23 uterus.
androgen insensitivity syndrome vs., 7:15 Noncommunicating uterine horn, hematosalpinx
differential diagnosis, 7:21–22 vs., 6:55
uterine hypoplasia/agenesis vs., 2:21 Nonteratomatous lipomatous ovarian tumor,
Multiparity lipomatous uterine tumors vs., 2:97
endocervical polyp associated with, 3:13 Northern European ancestry, vulvar carcinoma
risk factor for cervical carcinoma, 3:29 associated with, 4:62
Multiple pulmonary nodules, other causes: benign Nulliparity
metastasizing leiomyoma vs., 2:85 endometrial carcinoma associated with, 2:128
Multiple sex partners fallopian tube carcinoma associated with, 6:44
pelvic inflammatory disease associated with, 6:8 malignant mixed mesodermal tumor associated
pyosalpinx associated with, 6:16 with, 2:116
risk factor for cervical carcinoma, 3:29 risk factor for ovarian carcinoma, 5:47
tubo-ovarian abscess associated with, 6:20
O
MURCS syndrome, uterine hypoplasia/agenesis
MYC gene translocation, genital lymphoma
Myoma Obesity
cervical. See Cervical leiomyoma. endometrial carcinoma associated with, 2:128
degenerated. See Degenerated uterine leiomyoma. endometrial hyperplasia associated with, 2:108
pedunculated subserosal, parasitic leiomyoma malignant mixed mesodermal tumor associated
associated with, 2:81 with, 2:116
Myomectomy, laparoscopic: parasitic leiomyoma ovarian carcinoma associated with, 5:47
associated with, 2:82 Obstetric trauma
Myomectomy scar, post cesarean section appearance fecal incontinence associated with, 8:102
of uterus vs., 2:190 vaginal fistula associated with, 4:112
Myometrial contraction Obstructed defecation, clinical evaluation, 8:89
adenomyoma vs., 2:200 Obstructed defecation, imaging, 8:112–125
degenerated leiomyoma vs., 2:74 abnormalities of rectal evacuation, 8:112–113
congenital disorders, 8:113
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descending perineum syndrome, 8:112 Ovarian carcinoma, 5:40–61
INDEX
dyskinetic puborectalis, 8:113 classification, 5:46

intussusception and rectal prolapse, 8:112–113 clear cell, 5:98–103
rectocele, 8:112 differential diagnosis, 5:99–100
solitary rectal ulcer syndrome, 8:113 ovarian endometrioid carcinoma vs., 5:93
anatomic color Doppler in rectocele formation clinical issues, 5:50
(graphic), 8:117 natural history and prognosis, 5:50
anterior rectal wall mucosal prolapse on presentation, 5:50
conventional defecography, 8:123 treatment options by stage, 5:50
descending perineum syndrome, MR, 8:124 endometrioid, 5:92–97
dyskinetic puborectalis and anal sphincter differential diagnosis, 5:93
spasm, MR, 8:125 ovarian clear cell carcinoma vs., 5:99
etiological classification of constipation endometrioma associated with, 5:191
(graphic), 8:115 genital tuberculosis vs., 6:24
image findings, 8:113–114 image findings, 5:47–50
abnormalities of internal anal sphincter in detection, 5:47–48
patients with obstructed defecation, 8:114 restaging, 5:49–50
congenital disorders, 8:114 staging, 5:48–49
descending perineum syndrome, 8:113 image gallery, 5:52–61
dyskinetic puborectalis, 8:114 immature teratoma vs., 5:125
intussusception and rectal prolapse, 8:113 lymphoma vs., 5:183
rectocele, 8:113 ovarian carcinoid vs., 5:141
spastic anal sphincter contraction, 8:114 ovarian transitional cell carcinoma vs., 5:110
pathophysiology of constipation, 8:112 overview, 5:46
rectal intussusception and rectal prolapse pathology, 5:46–47
graphic, 8:120 general features, 5:46–47
MR, 8:121–122 routes of spread, 5:46
rectocele type I and type II groups, 5:47
conventional evacuation defecography, 8:118 primary, ovarian metastases vs., 5:177
MR defecography, 8:119 reporting checklist, 5:5:50–51
report template for evacuation proctography sclerosing stromal tumor vs., 5:173
(graphic), 8:116 serous, 5:80–85
Obstructed uterus, cervical stenosis vs., 3:9 staging
Oral contraceptive use AJCC Stages/Prognostic Groups, 5:40
adenosarcoma associated with, 2:111 (T), 5:40
disseminated peritoneal leiomyomatosis (N), 5:40
associated with, 2:95 (M), 5:40
long-term, risk factor for cervical carcinoma, 3:29 image findings, 5:48–49
Ovarian abscess metastases, organ frequency, 5:45
corpus luteal cyst vs., 5:20 nodal drainage, 5:45
endometrioma vs., 5:191 reporting checklist, 5:5:50–51
follicular cyst vs., 5:14 restaging (image findings), 5:49–50
Ovarian adenofibroma and cystadenofibroma, T1a (FIGO IA), 5:41, 43
5:74–79 T1b (FIGO IB), 5:43
Ovarian anatomy, 5:2–11 T1c (FIGO IC), 5:41, 43
anatomy imaging issues, 5:4 T2a (FIGO IIA), 5:42, 43
clinical implications, 5:4 T2b (FIGO IIB), 5:42, 44
CT, 5:10–11 T2c (FIGO IIC), 5:44
folliculogenesis (graphic), 5:5 T3 (FIGO III), 5:42
gross anatomy, 5:2–3 T3a (FIGO IIIA), 5:44
imaging anatomy, 5:3–4 T3b (FIGO IIIB), 5:44
MR, 5:8–9 T3c (FIGO IIIC), 5:42, 45
normal anatomy (graphic), 5:5 staging (images), 5:52–61
PET/CT, 5:11 stage IA (T1a N0 M0), 5:52–53
ultrasound, 5:6–7 stage IB (T1b N0 M0), 5:54
Ovarian carcinoid, 5:140–143 stage IC (T1c N0 M0), 5:54
differential diagnosis, 5:141 stage IIB (T2b N0 M0), 5:54–55
mucinous cystadenoma associated with, 5:70 stage IIIB (T3b N0 M0), 5:55–56
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stage IIIC (T1a N1 M0), 5:57 differential diagnosis, 5:35
INDEX
stage IIIC (T2b N1 M0), 5:57, 58 serous cystadenoma associated with, 5:64
stage IIIC (T3b N1 M0), 5:59 Ovarian leiomyoma/fibroma, tubal leiomyoma vs.,
stage IIIC (T3c N0 M0), 5:56–57 6:35
stage IIIC (T3c N0 M1), 5:59 Ovarian lesions, nonneoplastic, 5:188–225
stage IIIC (T3c N1 M0), 5:59 endometrioma. See Endometrioma.
stage IV (T3a N1 M1), 5:61 endometriosis. See Endometriosis.
stage IV (T3b N1 M1), 5:61 hyperstimulation syndrome. See Ovarian
stage IV (T3c N0 M1), 5:59–60, 61 hyperstimulation syndrome.
transitional cell, 5:108–113 peritoneal inclusion cysts. See Peritoneal
Ovarian carcinosarcoma (ovarian mixed müllerian inclusion cysts.
tumor), 5:104–107 polycystic ovary syndrome. See Polycystic ovary
differential diagnosis, 5:105 syndrome.
staging, grading, & classification, 5:105 Ovarian lymphoma, 5:182–187
Ovarian choriocarcinoma, 5:136–139 criteria for diagnosis, 5:184
differential diagnosis, 5:137–138 differential diagnosis, 5:183
ovarian yolk sac tumor vs., 5:133 ovarian metastases vs., 5:177
Ovarian clear cell carcinoma, 5:98–103 staging, grading, & classification, 5:183
differential diagnosis, 5:99–100 Ovarian maldescent
ovarian endometrioid carcinoma vs., 5:93 müllerian duct anomalies associated with, 2:18
staging, grading, & classification, 5:100 septate uterus associated with, 2:44
Ovarian cystadenocarcinoma. See Mucinous Ovarian masses
cystadenocarcinoma, ovarian. solid, parasitic leiomyoma vs., 2:81
Ovarian cysts with fibrous components, adenofibroma and
corpus luteal. See Corpus luteal cyst. cystadenofibroma vs., 5:76
follicular. See Follicular cyst. Ovarian metastases, 5:176–181
hemorrhagic. See Hemorrhagic ovarian cyst. adenofibroma and cystadenofibroma vs., 5:76
inclusion cyst, 5:34–39 carcinosarcoma vs., 5:105
differential diagnosis, 5:35 differential diagnosis, 5:177
serous cystadenoma associated with, 5:64 dysgerminoma vs., 5:129
paratubal cyst vs., 6:3 lymphoma vs., 5:183
tamoxifen-induced changes associated with, mucinous cystadenocarcinoma vs., 5:87
2:176 ovarian serous carcinoma vs., 5:81
theca lutein. See Theca lutein cysts. sclerosing stromal tumor vs., 5:173
Ovarian dermoid (mature teratoma). See Dermoid staging, grading, & classification, 5:177
(mature teratoma), ovarian. Ovarian mixed germ cell tumor, embryonal
Ovarian dysgerminoma. See Dysgerminoma. carcinoma and polyembryoma, 5:144–147
Ovarian edema, massive. See Massive ovarian edema differential diagnosis, 5:145
and fibromatosis. ovarian yolk sac tumor vs., 5:133
Ovarian endometrioid carcinoma, 5:92–97 staging, grading, & classification, 5:145
differential diagnosis, 5:93 Ovarian mucinous cystadenocarcinoma. See
ovarian clear cell carcinoma vs., 5:99 Mucinous cystadenocarcinoma, ovarian.
staging, grading, & classification, 5:94 Ovarian mucinous cystadenoma. See Mucinous
Ovarian epithelial inclusions. See Ovarian inclusion cystadenoma, ovarian.
cyst. Ovarian neoplasms
Ovarian fibroma. See Fibroma, thecoma, and acute adnexal torsion associated with, 5:238
fibrothecoma, ovarian. carcinoma. See Ovarian carcinoma.
Ovarian follicle, developing: ovarian inclusion cyst cystic, hydrosalpinx vs., 6:11
vs., 5:35 endometriosis associated with, 5:201
Ovarian granulosa cell tumor. See Granulosa cell epithelial. See Ovarian neoplasms, epithelial.
tumor. germ cell. See Ovarian neoplasms, germ cell.
Ovarian hyperstimulation syndrome, 5:208–211 hemorrhagic ovarian cyst vs., 5:30
differential diagnosis, 5:209 lymphoma, 5:182–187
follicular cyst vs., 5:14 differential diagnosis, 5:183
staging, grading, & classification, 5:209–210 ovarian metastases vs., 5:177
theca lutein cysts vs., 5:25–26 malignant, actinomycosis of fallopian tubes vs.,
Ovarian inclusion cyst, 5:34–39 6:27
associated abnormalities, 5:36 metastases. See Ovarian metastases.
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ovarian hyperstimulation syndrome vs., 5:209 struma ovarii, 5:148–153
INDEX
peritoneal inclusion cysts vs., 5:220 differential diagnosis, 5:150

sex cord-stromal. See Ovarian neoplasms, sex ovarian carcinoid vs., 5:141
cord-stromal. yolk sac tumor, 5:132–135
solid differential diagnosis, 5:133
lymphoma vs., 5:183 ovarian choriocarcinoma vs., 5:137
massive ovarian edema and fibromatosis vs., Ovarian neoplasms, sex cord-stromal
5:243 acute adnexal torsion associated with, 5:238
ovarian mixed germ cell tumor, embryonal corpus luteal cyst vs., 5:20
carcinoma and polyembryoma vs., 5:145 dysgerminoma vs., 5:129
parasitic leiomyoma vs., 2:81 fibroma, thecoma, and fibrothecoma. See
tubo-ovarian abscess vs., 6:19 Fibroma, thecoma, and fibrothecoma,
Ovarian neoplasms, epithelial ovarian.
acute adnexal torsion associated with, 5:238 granulosa cell tumor. See Granulosa cell tumor.
adenofibroma and cystadenofibroma, 5:74–79 ovarian mixed germ cell tumor, embryonal
carcinosarcoma (ovarian mixed müllerian carcinoma and polyembryoma vs., 5:145
tumor), 5:104–107 sclerosing stromal tumor, 5:172–175
clear cell carcinoma, 5:98–103 differential diagnosis, 5:173
differential diagnosis, 5:99–100 ovarian choriocarcinoma vs., 5:137
ovarian endometrioid carcinoma vs., 5:93 Sertoli-stromal cell tumors vs., 5:167
staging, grading, & classification, 5:100 Sertoli-stromal cell tumors, 5:166–171
endometrioid carcinoma, 5:92–97 sex cord tumor, with annular tubules: adenoma
differential diagnosis, 5:93 malignum associated with, 3:51
ovarian clear cell carcinoma vs., 5:99 Ovarian sclerosing stromal tumor, 5:172–175
granulosa cell tumor vs., 5:155 differential diagnosis, 5:173
malignant, ovarian yolk sac tumor vs., 5:133 ovarian choriocarcinoma vs., 5:137
mucinous cystadenocarcinoma. See Mucinous Sertoli-stromal cell tumors vs., 5:167
cystadenocarcinoma, ovarian. Ovarian serous carcinoma, 5:80–85
mucinous cystadenoma. See Mucinous differential diagnosis, 5:81
cystadenoma, ovarian. staging, grading, & classification, 5:81–82
other malignancies, carcinosarcoma vs., 5:105 type I and type II, 5:81
ovarian mixed germ cell tumor, embryonal Ovarian serous cystadenoma. See Serous
carcinoma and polyembryoma vs., 5:145 cystadenoma, ovarian.
serous carcinoma, 5:80–85 Ovarian Sertoli-stromal cell tumors, 5:166–171
serous cystadenoma. See Serous cystadenoma, Ovarian teratoma. See Teratoma.
ovarian. Ovarian torsion. See Acute adnexal torsion.
theca lutein cysts vs., 5:25 Ovarian transitional cell carcinoma, 5:108–113
transitional cell carcinoma, 5:108–113 differential diagnosis, 5:109–110
differential diagnosis, 5:109–110 staging, grading, & classification, 5:110
staging, grading, & classification, 5:110 Ovarian tumors
Ovarian neoplasms, germ cell estrogen-secreting, endometrial hyperplasia
carcinoid, 5:140–143 associated with, 2:108
differential diagnosis, 5:141 nonteratomatous lipomatous, lipomatous uterine
mucinous cystadenoma associated with, 5:70 tumors vs., 2:97
choriocarcinoma, 5:136–139 Ovarian vascular disorders
differential diagnosis, 5:137–138 acute adnexal torsion. See Acute adnexal torsion.
ovarian yolk sac tumor vs., 5:133 massive ovarian edema and fibromatosis. See
dermoid. See Dermoid (mature teratoma), ovarian. Massive ovarian edema and fibromatosis.
dysgerminoma. See Dysgerminoma. pelvic congestion syndrome, 5:232–235
immature teratoma, 5:124–127 differential diagnosis, 5:233
differential diagnosis, 5:125 polycystic ovary syndrome vs., 5:214
ovarian dermoid (mature teratoma) vs., 5:116 uterine arteriovenous malformation vs., 2:164
mixed germ cell tumor, embryonal carcinoma vein thrombosis. See Ovarian vein thrombosis.
and polyembryoma, 5:144–147 Ovarian vein thrombosis, 5:226–231
ovarian yolk sac tumor vs., 5:133 endometritis associated with, 2:59
intravenous leiomyomatosis vs., 2:91
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Ovarian yolk sac tumor, 5:132–135 genetics, 5:234
INDEX
differential diagnosis, 5:133 polycystic ovary syndrome vs., 5:214
ovarian choriocarcinoma vs., 5:137 uterine arteriovenous malformation vs., 2:164
staging, grading, & classification, 5:133 Pelvic diaphragm
Ovary coccygeus
multifollicular, polycystic ovary syndrome vs., anatomy (graphic), 8:12
5:214 axial oblique T2WI MR, 8:12
normal, polycystic ovary syndrome vs., 5:214 definition, 8:2
Ovotesticular disorders of sexual development, levator ani
ambiguous genitalia associated with, 7:18 anatomy (graphic), 8:13
Ovulation axial oblique T2WI MR, 8:13
hemorrhagic ovarian cyst associated with, 5:30 Pelvic floor anterior compartment imaging, 8:60–67
ovarian inclusion cyst associated with, 5:36 cystourethrography, 8:63
P
image gallery, 8:60, 64–67
imaging evaluation, 8:61
MR techniques, 8:61
ultrasound, 8:62–63
P53 gene mutation, endometrial carcinoma urethral support system defects, 8:62
associated with, 2:128 level III endopelvic fascial defect, 8:62
Paget disease, vulvar melanoma vs., 4:73 puborectalis muscle abnormalities, 8:62
Papillary endocervicitis, cervical glandular urethral ligament abnormalities, 8:62
hyperplasia vs., 3:65 urethral support system MR, 8:61–62
Papillary peritoneal cystosis, benign. See Peritoneal dorsal urethral ligaments, 8:62
inclusion cysts. endopelvic fascia, 8:62
Paraganglioma, vaginal, 4:28–31 normal urethral support system, 8:61
Paramesonephric system abnormalities, Gartner puborectalis muscle, 8:62
duct cysts associated with, 4:84 ventral urethral ligaments, 8:61–62
Paraovarian cyst. See Paratubal cyst. Pelvic floor anterior compartment overview, 8:40–59
Parasitic uterine leiomyoma, 2:80–83 female urethra, 8:40–41
differential diagnosis, 2:81 innervation (graphics), 8:44
uterine leiomyoma vs., 2:68 urethral ligaments
Paratubal cyst, 6:2–5 axial proton density MR, 8:49
acute adnexal torsion associated with, 5:238 axial T2WI TSE MR, 8:49
congenital uterine cysts vs., 2:53 grid for urethral ligament evaluation
differential diagnosis, 6:3 (graphic), 8:50
follicular cyst vs., 5:14 photograph, 8:48, 49
ovarian inclusion cyst vs., 5:35 sagittal proton density MR, 8:48
peritoneal inclusion cysts vs., 5:220 sagittal T2-weighted turbo spin-echo MR, 8:48
serous cystadenoma vs., 5:63 urethral MR, 8:47
Paraurethral gland cyst, distal. See Skene’s gland urethral sphincter, external (graphics), 8:45
cyst. urethral support system
Paraurethral ligaments axial T2WI MR, 8:51–54
anatomy, 8:41 components, 8:41
MR imaging, 8:62 endopelvic fascia, 8:41
Partial hydatidiform mole (PHM). See Hydatidiform ligaments, 8:41
mole, partial. puborectalis muscle, 8:41
Pedunculated leiomyoma. See Uterine leiomyoma, urethral wall (graphics), 8:45
pedunculated. urinary bladder
Pedunculated lipoleiomyoma, ovarian dermoid axial T2WI MR, 8:43
(mature teratoma) vs., 5:116 bladder support, 8:40
Pelvic abscess coronary T2WI MR, 8:43
degenerated leiomyoma vs., 2:74 frontal illustration (graphic), 8:43
other causes location and description, 8:40
actinomycosis of fallopian tubes vs., 6:27 urinary incontinence, 8:41–42
tubo-ovarian abscess vs., 6:20 etiology, 8:42
Pelvic congestion syndrome, 5:232–235 flow chart (graphic), 8:59
differential diagnosis, 5:233 general issues, 8:41
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sphincteric mechanism dysfunction, 8:42 Pelvic floor middle compartment overview, 8:68–79
INDEX
stress UI intrinsic sphincteric deficiency central fascial defect (graphics), 8:77

(graphics), 8:56 clinical evaluation of pelvic organ prolapse,
structure/function/pathological scheme 8:69–70
correlation (graphic), 8:58 clinical findings, 8:70
terminology and classification, 8:41–42 pelvic organ prolapse quantitation, 8:70
urethral support system dysfunction, 8:42 symptoms related to, 8:69–70
urge UI intrinsic detrusor instability defect-specific pelvic organ prolapse (graphic),
(graphics), 8:57 8:79
urodynamics (graphics), 8:55 etiology of pelvic organ prolapse (graphics), 8:78
Pelvic floor descent. See Descending perineum fascial defects (graphics), 8:75
syndrome. interaction between pelvic floor muscles and
Pelvic floor imaging, 8:30–39 endopelvic fascia (graphic), 8:71
analysis of dynamic images in sagittal plane, normal support system, 8:68
8:30–31 anterior vaginal wall support, 8:68
general principles, 8:30–31 normal vaginal fascial support (graphic), 8:74
pelvic organ prolapse, 8:31 posterior vaginal wall support, 8:68
stress urinary incontinence, 8:31 uterocervical support, 8:68
supportive measurements, 8:31 vaginal fascial support system (graphics), 8:72
before MR, 8:30 vaginal support, 8:68
dynamic MR paravaginal fascial defect
axial plane, 8:34 axial T2WI MR, 8:76
coronal plane, 8:35 graphic, 8:76
sagittal plane, 8:33 pathophysiology of pelvic organ prolapse, 8:69
sagittal plane measurements, 8:36 structural defects leading to pelvic organ
imaging technique, 8:30 prolapse, 8:68–69
indications, 8:30 anterior vaginal wall prolapse, 8:68–69
MR defecography, 8:31–32 posterior vaginal wall prolapse, 8:69
coronal plane, 8:38 vaginal vault prolapse, 8:69
ensuring proper dynamic MR techniques, 8:32 treatment of pelvic organ prolapse, 8:70
imaging technique, 8:32 uterocervical fascial support (graphics), 8:73
indications, 8:31 Pelvic floor multicompartmental defects, imaging,
patient preparation, 8:32 8:126–139
reporting, 8:32 back pain due to 3-compartment pelvic organ
sagittal plane, 8:37, 39 prolapse (images), 8:132
Pelvic floor ligaments clinical assessment, 8:126
anatomy (graphic), 8:7 3-axis perineal evaluation, 8:126
anatomy and functional correlation, 8:5 clinical examination sheet (graphic), 8:128
bony pelvis and ligaments (graphics), 8:7 physical exam, 8:126
endopelvic fascia (ligaments) competitive organ concept (images), 8:138
anatomy (graphic), 8:10–11 correlative analytic approach, 8:127
axial oblique T2WI TSE MR, 8:11 data integration, 8:127
Pelvic floor middle compartment imaging, 8:80–87 graphic, 8:129
dynamic contrast cystocolpoproctography, 8:82 treatment, 8:127
image gallery, 8:80, 83–87 diagnostic algorithm for MR imaging (graphic),
image interpretation, 8:81–82 8:130
classifying vaginal support system defects, 8:81 enlarging rectocele after surgery for stress
cystocele, 8:81 incontinence, 8:139
enterocele, 8:81 guidelines for MR indications in pelvic floor
grading of uterine prolapse and cystocele, dysfunction (graphic), 8:130
8:82 imaging, 8:126–127
masked stress urinary incontinence, 8:81–82 combined static and dynamic MR, 8:127
normal vaginal support system, 8:81 general, 8:126–127
vaginal vault prolapse, 8:82 overview, 8:126
MR, 8:81 pelvic floor dysfunction
perineal ultrasound in pelvic organ prolapse, 8:82 clinical assessment, 8:126
treatment of pelvic organ prolapse, 8:82 guidelines for MR indications (graphic), 8:130
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rectal prolapse due to sphincter deficiency and pelvic floor muscle and endopelvic fascial
INDEX
level I fascial defect, 8:137 interaction, 8:5
stress urinary incontinence, diagnosis (images) functional 3-part pelvic support system
3-compartment pelvic organ prolapse, 8:131 axial balanced fast field echo MR, 8:20
multiple fascial defects, 8:135 axial T2WI MR, 8:20
muscle weakness, 8:134 iliococcygeus muscle, MR anatomy, 8:4, 23–25
pelvic organ prolapse and intussusception, lateral pelvic wall anatomy
8:133 graphic, 8:9
pelvic organ prolapse and sigmoidocele, 8:136 sagittal T1WI MR, 8:9
Pelvic floor muscles levator ani muscle
axial MR, 8:27 anatomy (graphic), 8:13
coronal MR, 8:28 axial oblique MR, 8:13, 21
endopelvic fascial interaction with, 8:5 components, 8:3
MR, 8:26 functional correlation, 8:3
sagittal MR, 8:29 innervation, 8:3
Pelvic floor overview, 8:2–29 ligaments
1st layer pelvic floor: endopelvic fascia anatomy (graphic), 8:7
(ligaments) anatomy and functional correlation, 8:5
anatomy (graphic), 8:10–11 endopelvic fascia (ligaments)
axial oblique T2WI TSE MR, 8:11 anatomy (graphic), 8:10–11
2nd layer pelvic floor: pelvic diaphragm axial oblique T2WI TSE MR, 8:11
(coccygeus) MR anatomy
anatomy (graphic), 8:12 iliococcygeus muscle, 8:4
axial oblique T2WI MR, 8:12 levator plate, 8:4
2nd layer pelvic floor: pelvic diaphragm (levator puborectalis muscle, 8:3–4
ani) pelvic diaphragm
anatomy (graphic), 8:13 coccygeus
axial oblique T2WI MR, 8:13 anatomy (graphic), 8:12
3rd layer pelvic floor: urogenital diaphragm axial oblique T2WI MR, 8:12
anatomy (graphic), 8:14 definition, 8:2
axial oblique T2WI MR, 8:15 levator ani
coronal T2WI MR, 8:15 anatomy (graphic), 8:13
4th layer pelvic floor: superficial external genital axial oblique T2WI MR, 8:13
muscles pelvic floor muscles
anatomy (graphic), 8:16 axial MR, 8:27
axial oblique T2WI MR, 8:16 coronal MR, 8:28
approaches for functional description, 8:2 endopelvic fascial interaction with, 8:5
active and passive conceptual approach, 8:2 MR, 8:26
classic 3-compartment approach, 8:2 sagittal MR, 8:29
functional 3-part pelvic supporting systems pelvic support system
approach, 8:2 functional 3-part
multilayered system approach, 8:2 axial balanced fast field echo MR, 8:20
bony pelvis axial T2WI MR, 8:20
anatomy (graphic), 8:7 passive and active components (graphics),
functional correlation, 8:2 8:18–19
osseous structures, 8:2 pelvic wall, 8:2
coccygeus muscle perineum, 8:6
anatomy (graphic), 8:12 posterior pelvic wall anatomy
anatomy and function, 8:3 coronal T2WI MR, 8:8
axial oblique T2WI MR, 8:12 graphic, 8:8
comparative male anatomy puborectalis muscle, MR, 8:22
axial T2WI MR, 8:17 superficial external genital muscles, 8:6
graphic, 8:17 supportive connective tissue, 8:4–5
endopelvic fascia anatomy and functional correlation, 8:4–5
anatomy and functional correlation, 8:5 endopelvic fascia, 8:5
axial oblique T2WI TSE MR, 8:11 levels of vaginal support, 8:5
graphic, 8:10–11 ligaments, 8:5
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urogenital diaphragm (perineal membrane) sagittal T2WI MR, 8:94
INDEX
anatomy (graphic), 8:14 Pelvic fluid collections, endometritis associated

axial oblique T2WI MR, 8:15 with, 2:59
coronal T2WI MR, 8:15 Pelvic inflammatory disease, 6:6–9
location and description, 8:5–6 acute adnexal torsion vs., 5:237
Pelvic floor posterior compartment imaging differential diagnosis, 6:7–8
fecal incontinence. See Fecal incontinence, genital tuberculosis vs., 6:24
imaging. hematosalpinx associated with, 6:55
obstructed defecation. See Obstructed defecation, salpingitis isthmica nodosa associated with, 6:31
imaging. tuberculous, actinomycosis of fallopian tubes vs.,
Pelvic floor posterior compartment overview, 6:27
8:88–101 Pelvic lipoma, benign: lipomatous uterine tumors
anal sphincter complex anatomy, 8:88 vs., 2:97
coronal T2WI MR, 8:95 Pelvic liposarcoma, lipomatous uterine tumors vs.,
external anal sphincter, 8:88 2:97
graphic, 8:95 Pelvic lymphadenopathy
internal anal sphincter, 8:88 malignant mixed mesodermal tumor associated
intersphincteric space and longitudinal with, 2:116
smooth muscle layer, 8:88 pelvic congestion syndrome vs., 5:233
MR appearance, 8:89–90, 96–99 Pelvic malignancy, vaginal fistula associated with,
puborectalis muscle, 8:88 4:112
anorectal dysfunction, anorectal physiology Pelvic organ prolapse. See also Pelvic floor middle
tests, 8:89 compartment overview.
anorectal manometry, 8:89 back pain associated with (images), 8:131
electromyography, 8:89 clinical evaluation, 8:69–70
motor-evoked potentials, 8:89 clinical findings, 8:70
pudendal nerve terminal motor latency test, pelvic organ prolapse quantitation, 8:70
8:89 symptoms related to, 8:69–70
Sitzmarks transit study, 8:89 dynamic contrast cystocolpoproctography, 8:82
anorectal dysfunction, clinical evaluation, 8:88–89 dynamic images in sagittal plane, 8:31
assessment of anal sphincter and pelvic floor, graphic illustrations
8:89 central fascial defect, 8:77
constipation and obstructed defecation, 8:89 defect-specific pelvic organ prolapse, 8:79
fecal incontinence, 8:88–89 etiology of pelvic organ prolapse, 8:78
anorectal region physiology, 8:88 fascial defects, 8:75
factors contributing to anal continence, 8:88 paravaginal fascial defect, 8:76
rectoanal inhibitory reflex, 8:88 image gallery, 8:80, 83–87
conventional evacuation proctography image interpretation, 8:81–82
(“defecography”), 8:91–92 classifying vaginal support system defects,
findings in normal subjects, 8:92 8:81
image analysis, 8:91 cystocele and enterocele, 8:81
images, 8:100 grading of uterine prolapse and cystocele, 8:82
indications, 8:91 masked stress urinary incontinence, 8:81–82
limitations, 8:92 normal vaginal support system, 8:81
technique, 8:91 vaginal vault prolapse, 8:82
dynamic and static phased-array MR, 8:89–90 pathophysiology, 8:69
dimensions of anal sphincter complex, 8:90 perineal ultrasound, 8:82
imaging planes and field of view, 8:89 stress urinary incontinence associated with
MR appearance of anal sphincter complex, (images)
8:89–90 3-compartment POP, 8:131
technique, 8:89 POP and intussusception, 8:133
topographic MR anatomy, 8:90 POP and sigmoidocele, 8:136
endoanal MR, 8:91 structural defects leading to prolapse, 8:68–69
endoanal sonography, 8:92 anterior vaginal wall prolapse, 8:68–69
rectum and anal canal anatomy posterior vaginal wall prolapse, 8:69
anatomical relations and subdivisions vaginal vault prolapse, 8:69
(transanal endosonography), 8:101 treatment, 8:70, 82
graphics, 8:93–94
xxiv Obgyne Books Full

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Pelvic support system staging (images)
INDEX
connective tissue, 8:4–5 H&E stain, 2:147
anatomy and functional correlation, 8:4–5 T1, 2:159
endopelvic fascia, 8:5 T2, 2:160
levels of vaginal support, 8:5 treatment options, 2:153
ligaments, 8:5 Pleuropulmonary blastoma, Sertoli-stromal cell
functional 3-part tumors associated with, 5:167–168
axial balanced fast field echo MR, 8:20 Plexiform neurofibroma, vulvar hemangioma vs.,
axial T2WI MR, 8:20 4:25
passive and active components (graphics), Polycystic ovaries, polycystic ovary syndrome vs.,
8:18–19 5:214
Pelvic varices. See Pelvic congestion syndrome. Polycystic ovary syndrome, 5:212–217
Pelvic veins, distended, hydrosalpinx vs., 6:11–12 differential diagnosis, 5:214
Pelvic wall anatomy endometrial carcinoma associated with, 2:128
anterior, 8:2 genetics, 5:214
lateral ovarian hyperstimulation syndrome vs., 5:209
graphic, 8:9 theca lutein cysts vs., 5:25
overview, 8:2 Polyembryoma. See Ovarian mixed germ cell tumor,
sagittal T1WI MR, 8:9 embryonal carcinoma and polyembryoma.
posterior Polypoid adenomyoma, endometrial polyps vs.,
coronal T2WI MR, 8:8 2:101
graphic, 8:8 Poorly differentiated adenocarcinoma, cervical,
overview, 8:2 3:29–30
Perforated appendicitis, pelvic inflammatory disease Positron emission tomography. See PET/CT
vs., 6:7–8 technique and imaging issues.
Perineal ultrasound in pelvic organ prolapse, 8:82 Post dilation and curettage, pyomyoma associated
Perineum, anatomy, 8:6 with, 2:63
Peritoneal inclusion cysts, 5:218–225 Post-trachelectomy appearance, cervix, 3:62–63
differential diagnosis, 5:220 Post cesarean section appearance of uterus, 2:188–
hematosalpinx vs., 6:55 191
hydrosalpinx vs., 6:11 Posterior compartment of pelvic floor
mucinous cystadenoma vs., 5:69 imaging. See Fecal incontinence, imaging;
paratubal cyst vs., 6:3 Obstructed defecation, imaging.
Peritoneal tumor implants, endometriosis vs., 5:201 overview. See Pelvic floor middle compartment
Peritonitis, ruptured tubo-ovarian abscess associated overview.
with, 6:20 Posterior pelvic wall anatomy
Periurethral collagen injections, Gartner duct cysts coronal T2WI MR, 8:8
vs., 4:84 graphic, 8:8
Periurethral ligament overview, 8:2
anatomy, 8:41 Posterior vaginal wall prolapse, 8:69
MR imaging, 8:62 Posterior vaginal wall support, normal, 8:68
PET/CT technique and imaging issues, 1:28–33 Postmenopausal patients, pyomyoma associated
Peutz-Jeghers syndrome, adenoma malignum with, 2:63
associated with, 3:51 Postoperative peritoneal cysts. See Peritoneal
Pheochromocytoma, vaginal. See Vaginal inclusion cysts.
paraganglioma. Postpartum cervix with ectropion, nabothian cysts
PHM (partial hydatidiform mole). See Hydatidiform associated with, 3:69
mole, partial. Postpartum period, pyomyoma associated with, 2:63
Physiologic ovarian cyst. See Follicular cyst. Postpartum uterus: Asherman syndrome,
Placenta accreta: Asherman syndrome, endometrial endometrial synechiae associated with, 2:55
synechiae associated with, 2:55 Postuterine artery embolization, pyomyoma
Placental-site trophoblastic tumor. See also associated with, 2:63
Gestational trophoblastic disease. Pouch. See Post cesarean section appearance of
gross pathology and surgical features, 2:151 uterus.
imaging findings, 2:151 Pregnancy
microscopic pathology, 2:151 choriocarcinoma associated with, 2:150
routes of spread, 2:150 disseminated peritoneal leiomyomatosis
Obgyne Books Full xxv

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ectopic. See Ectopic pregnancy. Reactive atypias, cervical glandular hyperplasia vs.,
INDEX
molar, gestational trophoblastic disease 3:65

associated with, 2:150 Rectal evacuation abnormalities, 8:112–113
ovarian choriocarcinoma associated with, 5:138 congenital disorders, 8:113
ovarian vein thrombosis associated with, 5:228 descending perineum syndrome, 8:112
Primary cutaneous neuroendocrine carcinoma. See dyskinetic puborectalis, 8:113
Merkel cell tumor, vulvar. intussusception and rectal prolapse, 8:112–113
Progestogenic therapy, nabothian cysts associated rectocele, 8:112
with, 3:70 solitary rectal ulcer syndrome, 8:113
Pseudohermaphroditism. See Ambiguous genitalia. Rectal intussusception and prolapse. See
Pseudoneoplastic glandular lesions, other, cervical Intussusception and rectal prolapse.
glandular hyperplasia vs., 3:65 Rectoanal inhibitory reflex, 8:88
PTEN gene mutation, endometrial carcinoma Rectocele
associated with, 2:128 anatomic considerations in formation (graphic),
Puborectalis muscle, anterior pelvic compartment 8:117
abnormalities, 8:62 clinical findings related to pelvic organ prolapse,
anatomy and function, 8:41 8:70
MR imaging, 8:62 conventional evacuation defecography image,
Puborectalis muscle, dyskinetic 8:118
image findings, 8:114 enlarging, after urinary stress incontinence
MR imaging, 8:125 surgery (images), 8:139
rectal evacuation abnormalities associated with, image findings, 8:113
8:113 rectal evacuation abnormalities associated with,
Puborectalis muscle, MR anatomy, 8:3–4, 22 8:112
Pubourethral ligaments Rectovaginal fistula, fecal incontinence associated
components, 8:41 with, 8:102
MR imaging, 8:61–62 Rectum and anal canal anatomy
Pudendal anatomy. See Vulvar anatomy. anatomical relations and subdivisions (transanal
Pudendal nerve terminal motor latency test, for endosonography), 8:101
anorectal dysfunction, 8:89 graphics, 8:93–94
Puerperium, ovarian vein thrombosis associated sagittal T2WI MR, 8:94
with, 5:228 Renal anomalies
Pulmonary nodules, multiple, other causes: benign ambiguous genitalia associated with, 7:18
metastasizing leiomyoma vs., 2:85 bicornuate uterus associated with, 2:40
Pulsatile angioma. See Uterine arteriovenous müllerian duct anomalies associated with, 2:18
malformation. uterus didelphys associated with, 2:33
Pyomyoma, 2:62–65 Renal cell carcinoma invading inferior vena cava
Pyosalpinx, 6:14–17 and right atrium, intravenous leiomyomatosis
differential diagnosis, 6:15 vs., 2:91
hematosalpinx vs., 6:55 Retained products of conception
hydrosalpinx vs., 6:11 endometritis vs., 2:59
ovarian vein thrombosis vs., 5:228 uterine arteriovenous malformation vs., 2:164
peritoneal inclusion cysts vs., 5:220 Retention cysts of cervix. See Nabothian cysts,
R
cervical.
Rhabdomyosarcoma
bladder, vaginal embryonal rhabdomyosarcoma
vs., 4:47
Racemose aneurysm. See Uterine arteriovenous cervical, 3:55
malformation. genital lymphoma vs., 7:3
Radiation necrosis, post-trachelectomy appearance vaginal. See Vaginal embryonal
vs., 3:63 rhabdomyosarcoma.
Radiation therapy Right-sided heart thrombus in transit, intravenous
cervical stenosis associated with, 3:9 leiomyomatosis vs., 2:91
vaginal fistula associated with, 4:112
xxvi Obgyne Books Full

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S
Septate uterus, 2:42–47
INDEX
arcuate uterus vs., 2:49
associated abnormalities, 2:44
bicornuate uterus vs., 2:39
Salpingitis class U2 of ESHRE/ESGE consensus, 2:43
endometritis associated with, 2:59 class V müllerian duct anomaly, 2:43
hydrosalpinx vs., 6:11 differential diagnosis, 2:43
pyosalpinx associated with, 6:16 partial, DES exposure vs., 2:51
salpingitis isthmica nodosa vs., 6:31 staging, grading, & classification, 2:44
Salpingitis isthmica nodosa, 6:30–33 Serous adenocarcinoma, ovary
differential diagnosis, 6:31 mucinous cystadenocarcinoma vs., 5:87
staging, grading, & classification, 6:32 ovarian clear cell carcinoma vs., 5:99
Sarcoma ovarian endometrioid carcinoma vs., 5:93
carcinosarcoma. See Carcinosarcoma. Serous carcinoma, ovarian, 5:80–85
cervical, 3:54–57 differential diagnosis, 5:81
endometrial stromal, 2:142–145 staging, grading, & classification, 5:81–82
Ewing sarcoma, cervical, 3:55 type I and type II, 5:81
leiomyosarcoma. See Leiomyosarcoma. Serous cystadenoma, ovarian, 5:62–67
liposarcoma benign
pelvic, lipomatous uterine tumors vs., 2:97 mucinous cystadenocarcinoma vs., 5:87
undifferentiated endocervical sarcoma, 3:55, ovarian clear cell carcinoma vs., 5:99
56 ovarian serous carcinoma vs., 5:81
müllerian adenosarcoma, endocervical polyp vs., differential diagnosis, 5:63–64
3:13 dysgerminoma vs., 5:129
rhabdomyosarcoma mucinous cystadenoma vs., 5:69
bladder, vaginal embryonal ovarian endometrioid carcinoma vs., 5:93
rhabdomyosarcoma vs., 4:47 ovarian inclusion cyst vs., 5:35
cervical, 3:55 ovarian transitional cell carcinoma associated
genital lymphoma vs., 7:3 with, 5:110
vaginal. See Vaginal embryonal Sertoli-stromal cell tumors, 5:166–171
rhabdomyosarcoma. differential diagnosis, 5:166
uterine adenosarcoma, 2:110–113 genetics, 5:166–167
uterine epithelioid endometrial stromal sarcoma, staging, grading, & classification, 5:168
endocervical polyp vs., 3:13 Sex cord-stromal tumors. See Ovarian neoplasms,
uterine leiomyosarcoma. See Uterine sex cord-stromal.
leiomyosarcoma. Sex partners, multiple
uterine sarcomas, other pelvic inflammatory disease associated with, 6:8
adenosarcoma vs., 2:111 pyosalpinx associated with, 6:16
endometrial stromal sarcoma vs., 2:143 risk factor for cervical carcinoma, 3:29
uterine leiomyosarcoma vs., 2:121 tubo-ovarian abscess associated with, 6:20
vaginal embryonal rhabdomyosarcoma. See Sexual activity, early age, risk factor for cervical
Vaginal embryonal rhabdomyosarcoma. carcinoma, 3:29
vaginal leiomyosarcoma, 4:44–45 Sexual development, abnormal
differential diagnosis, 4:45 ambiguous genitalia, 7:16–19
vaginal leiomyoma vs., 4:19 differential diagnosis, 7:18
vaginal sarcoma, vaginal melanoma vs., 4:73 genetics, 7:18
vulvar leiomyosarcoma, 4:70–71 uterine hypoplasia/agenesis vs., 2:21
Sarcoma botryoides, endocervical polyp vs., 3:13 androgen insensitivity syndrome, 7:14–15
Sarcomatous degeneration of uterine leiomyoma, differential diagnosis, 7:15
lipomatous uterine tumors vs., 2:97 genetics, 7:15
Sclerosing stromal tumor, 5:172–175 gonadal dysgenesis vs., 7:21
differential diagnosis, 5:173 uterine hypoplasia/agenesis vs., 2:21
ovarian choriocarcinoma vs., 5:137 gonadal dysgenesis, 7:20–23
Sertoli-stromal cell tumors vs., 5:167 androgen insensitivity syndrome vs., 7:15
Secretory endometrium, endometrial hyperplasia differential diagnosis, 7:21–22
vs., 2:107 genetics, 7:22
Segmental adenomyosis, adenomyoma vs., 2:199 uterine hypoplasia/agenesis vs., 2:21
Senile atrophy, cervical stenosis associated with, 3:9
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Sexual development disorders. See Ambiguous Struma ovarii, 5:148–153
INDEX
genitalia; Gonadal dysgenesis. differential diagnosis, 5:150

Sitzmarks transit study, for anorectal dysfunction, ovarian carcinoid vs., 5:141
8:89 staging, grading, & classification, 5:150
Skene’s gland cyst, 4:98–101 Strumal carcinoid, struma ovarii associated with,
Bartholin cysts vs., 4:87 5:150
bartholinitis vs., 4:91 Submucosal uterine leiomyoma. See Uterine
differential diagnosis, 4:99 leiomyoma, submucosal.
Gartner duct cysts vs., 4:83 Subserosal endometriosis, adenomyoma vs., 2:200
urethral diverticulum vs., 4:96 Subserosal leiomyoma. See Uterine leiomyoma,
Small bowel obstruction subserosal.
hydrosalpinx vs., 6:11 Suburethral ligament
pyosalpinx vs., 6:15 anatomy, 8:41
Small cell carcinoma, cervical, general features, MR imaging, 8:62
3:28–29 Superficial external genital muscles, anatomy and
Smoking functional correlation, 8:6
risk factor for cervical carcinoma, 3:29 Suppurative leiomyoma. See Pyomyoma.
vulvar carcinoma associated with, 4:62 Surface epithelial inclusion cysts, ovarian inclusion
Smooth muscle metaplasia of subperitoneal cyst associated with, 5:36
pluripotent mesenchymal stem cells, Surface epithelial tumor
disseminated peritoneal leiomyomatosis corpus luteal cyst vs., 5:20
associated with, 2:95 follicular cyst vs., 5:14
Solid ovarian neoplasms Surgical damage, fecal incontinence associated with,
lymphoma vs., 5:183 8:102
T
massive ovarian edema and fibromatosis vs., 5:243
ovarian mixed germ cell tumor, embryonal
carcinoma and polyembryoma vs., 5:145
parasitic leiomyoma vs., 2:81
Solitary rectal ulcer syndrome, rectal evacuation Tamoxifen-induced changes, 2:174–179
abnormalities associated with, 8:113 adenomyosis associated with, 2:194
Sonohysterography, 1:16–17 adenosarcoma associated with, 2:111
Spastic anal sphincter contraction, image findings, differential diagnosis, 2:175
8:114 endocervical polyp associated with, 3:13
Squamocolumnar junction, origin of cervical endometrial carcinoma associated with, 2:128
carcinoma, 3:28 endometrial hyperplasia associated with, 2:108
Squamous cell carcinoma, cervical endometrial polyps associated with, 2:101
general features, 3:28 malignant mixed mesodermal tumor associated
microscopic pathology with, 2:116
large cell nonkeratinizing, 3:29 spectrum of endometrial abnormalities, 2:175
morphologic variants, 3:29 Techniques, 1:2–33
small cell nonkeratinizing, 3:29 CT technique and anatomy, 1:18–21
nabothian cysts vs., 3:69 hysterosalpingography, 1:8–15
Squamous cell carcinoma, vaginal MR technique and anatomy, 1:22–27
pathology PET/CT technique and imaging issues, 1:28–33
general features, 4:36 sonohysterography, 1:16–17
gross pathology & surgical features, 4:36 ultrasound technique and anatomy, 1:2
microscopic pathology, 4:36 Teratoma
treatment options by stage, 4:38 cystic ovarian
Squamous cell carcinoma, vulvar: vulvar melanoma benign, lipomatous uterine tumors vs., 2:97
vs., 4:73 mucinous cystadenoma vs., 5:69
Stasis of blood flow, ovarian vein thrombosis immature, 5:124–127
associated with, 5:228 differential diagnosis, 5:125
Stein-Leventhal syndrome. See Polycystic ovary ovarian dermoid (mature teratoma) vs., 5:116
syndrome. staging, grading, & classification, 5:126
Stromal tumors. See Ovarian neoplasms, sex cord- mature. See Dermoid (mature teratoma), ovarian.
stromal. mucinous cystadenoma associated with, 5:70
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U
Testicular feminization. See Androgen insensitivity
INDEX
syndrome.
Thalidomide, müllerian duct anomalies associated
with, 2:18
Ultrasound technique and anatomy, 1:2–7
Theca lutein cysts, 5:24–27
Undifferentiated endocervical sarcoma, cervical,
corpus luteal cyst vs., 5:20
3:55
Unicornuate uterus, 2:26–31
gestational trophoblastic disease associated with,
class II müllerian duct anomaly, 2:27
2:150
ovarian hyperstimulation syndrome vs., 5:209
genetics, 2:27
Thecoma. See Fibroma, thecoma, and fibrothecoma,
ovarian.
uterus didelphys vs., 2:33
Thyroid cancer, metastatic to ovary: struma ovarii
with rudimentary horn
vs., 5:150
bicornuate uterus vs., 2:39
Trabecular carcinoma. See Merkel cell tumor, vulvar.
septate uterus vs., 2:43
Transitional cell carcinoma, ovarian, 5:108–113
Unilocular cystic lesions, adenofibroma and
cystadenofibroma vs., 5:75
Unopposed estrogen stimulation, endometrial
Transitional cell metaplasia, ovarian transitional cell
hyperplasia associated with, 2:107
carcinoma associated with, 5:110
Ureterocele, ectopic: Gartner duct cysts vs., 4:83
Traumatic rupture, fecal incontinence associated
Urethra, female, 8:40–41
with, 8:102
functional correlation of urethral wall, 8:40
Triploid karyotype, partial hydatidiform mole
innervation, 8:41
location and description, 8:40
Trousseau syndrome (venous thromboembolism),
topographic anatomy, 8:40–41
ovarian endometrioid carcinoma associated
Urethral caruncle, Skene’s gland cyst vs., 4:99
with, 5:100
Urethral diverticulum, 4:94–97
Tubal adenomyosis/diverticulosis. See Salpingitis
Bartholin cysts vs., 4:88
isthmica nodosa.
Tubal endometriosis, salpingitis isthmica nodosa vs.,
6:31
Skene’s gland cyst vs., 4:99
Tubal leiomyoma, 6:34–37
Urethral ligaments
Tubal ligation
axial proton density MR, 8:49
bilateral (BTL). See Contraceptive device
axial T2WI TSE MR, 8:49
evaluation.
dorsal urethral ligaments, 8:41, 62
hematosalpinx associated with, 6:55
grid for urethral ligament evaluation (graphic),
hydrosalpinx associated with, 6:12
8:50
Tuberculosis, salpingitis isthmica nodosa vs., 6:31
paraurethral, 8:41, 62
Tuberculous pelvic inflammatory disease. See Genital
periurethral, 8:41, 62
tuberculosis.
photograph, 8:48, 49
Tuberculous salpingitis. See Genital tuberculosis.
pubourethral, 8:41, 61–62
Tubo-ovarian abscess, 6:18–21
sagittal proton density MR, 8:48
degenerated leiomyoma vs., 2:74
sagittal T2 weighted turbo spin-echo MR, 8:48
suburethral, 8:41, 62
endometritis associated with, 2:59
ventral, MR imaging, 8:61–62
hemorrhagic ovarian cyst vs., 5:30
Urethral MR, anterior pelvic compartment, 8:47
immature teratoma vs., 5:125
Urethral sphincter, external (graphics), 8:45
mucinous cystadenoma vs., 5:69
Urethral support system
ovarian choriocarcinoma vs., 5:138
components, 8:41
pyogenic, actinomycosis of fallopian tubes vs.,
endopelvic fascia, 8:41
6:27
ligaments, 8:41
Tuboplasty, hematosalpinx associated with, 6:55
puborectalis muscle, 8:41
Tunnel clusters. See Nabothian cysts, cervical.
Urethral support system defects, 8:62
Turner syndrome, gonadal dysgenesis associated
level III endopelvic fascial defect, 8:62
with, 7:22
puborectalis muscle abnormalities, 8:62
urethral ligament abnormalities, 8:62
xxix

INDEX
Urethral support system MR imaging, 8:61–62 differential diagnosis, 2:203
INDEX
axial T2WI MR images, 8:51–54 unicornuate uterus vs., 2:27

dorsal urethral ligaments, 8:62 deep, Asherman syndrome, endometrial
endopelvic fascia, 8:62 synechiae associated with, 2:55
normal urethral support system, 8:61 differential diagnosis, 2:194
puborectalis muscle, 8:62 diffuse, adenomyoma associated with, 2:200
ventral urethral ligaments, 8:61–62 endometrial stromal sarcoma vs., 2:143
Urethral tumors, urethral diverticulum vs., 4:96 endometrioma associated with, 5:191
Urethral wall (graphics), 8:45 endometriosis associated with, 5:201
Urinary bladder focal, degenerated leiomyoma vs., 2:74
axial T2WI MR, 8:43 malignant mixed mesodermal tumor vs., 2:116
bladder support, 8:40 salpingitis isthmica nodosa vs., 6:31
coronary T2WI MR, 8:43 segmental, adenomyoma vs., 2:199
frontal illustration (graphic), 8:43 uterine leiomyosarcoma vs., 2:121
location and description, 8:40 Uterine adenomyotic cysts, congenital uterine cysts
Urinary bladder rhabdomyosarcoma, vaginal vs., 2:53
embryonal rhabdomyosarcoma vs., 4:47 Uterine adenosarcoma, 2:110–113
Urinary incontinence, 8:41–42 Uterine agenesis, ambiguous genitalia vs., 7:18
diagnosis of stress UI in pelvic Uterine anatomy, 2:2–15
multicompartmental defects (images) anatomic relationships, 2:2–3
3-compartment pelvic organ prolapse, 8:131 anatomy (graphic), 2:5
multiple fascial defects, 8:135 anatomy imaging issues, 2:4
muscle weakness, 8:134 arterial blood supply, 2:3
pelvic organ prolapse and intussusception, arteries (graphic), 2:5
8:133 CT of uterine anatomy, 2:13
pelvic organ prolapse and sigmoidocele, 8:136 embryology
etiology, 8:42 graphic, 2:6
flow chart, 8:59 uterine development, 2:4
general issues, 8:41 extraperitoneal position, 2:2
masked stress incontinence, in pelvic organ fallopian tubes, anatomic relationship, 2:2–3
prolapse, 8:81–82 gross anatomy, 2:2–3
sphincteric mechanism dysfunction, 8:42 imaging anatomy, 2:3–4
stress UI intrinsic sphincteric deficiency lymphatic drainage, 2:3
(graphics), 8:56 MR
structure/function/pathological scheme cervical zonal anatomy, 2:12
correlation, 8:58 premenarchal and postmenopausal uterus,
terminology and classification, 8:41–42 2:11
urethral support system dysfunction, 8:42 uterine zonal anatomy, 2:10
urge UI intrinsic detrusor instability (graphics), MRA of uterine vasculature, 2:6
8:57 positioning, 2:2
Urinary tract anomalies, ambiguous genitalia premenarche, menarche, postmenopausal
associated with, 7:18 gross anatomy, 2:2
Urodynamics (graphics), 8:55 MR, 2:3–4, 11
Urogenital diaphragm (perineal membrane) supporting ligaments, 2:2
anatomy (graphic), 8:14 ultrasound images
axial oblique T2WI MR, 8:15 age-related appearance, 2:7
coronal T2WI MR, 8:15 cyclical appearance of endometrium, 2:8
location and description, 8:5–6 hysterosalpingogram, 2:9
Urogenital triangle of perineum, 8:6 normal endometrium, 2:9
Uterine adenomyoma, 2:198–201 SIS (saline-infused sonohysterogram), 2:9
differential diagnosis, 2:199–200 tubal anatomy, 2:9
focal, degenerated leiomyoma vs., 2:74 vasculature (graphic), 2:6
polypoid, endometrial polyps vs., 2:101 venous drainage, 2:3
uterine leiomyoma vs., 2:68 Uterine arteriovenous malformation, 2:162–167. See
Uterine adenomyosis, 2:192–197 also Uterine vascular malformation.
adenosarcoma vs., 2:111 associated abnormalities, 2:164
cystic, 2:202–205 differential diagnosis, 2:164
pelvic congestion syndrome vs., 5:233
xxx

INDEX
post-treatment arteriovenous fistula (images), infected. See Pyomyoma.
INDEX
2:161 malignant mixed mesodermal tumor vs., 2:116
Uterine artery embolization, cystic adenomyosis natural history and prognosis, 2:69
associated with, 2:204 parasitic, 2:80–83
Uterine artery embolization imaging, 2:168–173 differential diagnosis, 2:81
Uterine artery pseudoaneurysm, uterine uterine leiomyoma vs., 2:68
arteriovenous malformation associated with, pedunculated
2:164 cervical leiomyoma vs., 3:17
Uterine contraction, leiomyoma vs., 2:68 congenital uterine cysts vs., 2:53
Uterine cysts, congenital, 2:52–53 fibroma, thecoma, and fibrothecoma vs.,
criteria, by Sherrick and Vega, 2:53 5:161
differential diagnosis, 2:53 multiple, disseminated peritoneal
Uterine cysts, miscellaneous: cystic adenomyosis vs., leiomyomatosis vs., 2:95
2:203 subserosal
Uterine epithelioid endometrial stromal sarcoma, ovarian transitional cell carcinoma vs.,
endocervical polyp vs., 3:13 5:110
Uterine fibroid embolization. See Uterine artery parasitic leiomyoma associated with, 2:81
embolization imaging. unicornuate uterus vs., 2:27
Uterine fibroids. See Uterine leiomyoma. submucosal
degenerated. See Degenerated uterine leiomyoma. arcuate uterus vs., 2:49
parasitic. See Parasitic uterine leiomyoma. Asherman syndrome, endometrial synechiae
Uterine hemangioma, uterine arteriovenous vs., 2:55
malformation vs., 2:164 endometrial hyperplasia vs., 2:107
Uterine horn, noncommunicating: hematosalpinx endometrial polyps vs., 2:101
vs., 6:55 tamoxifen-induced changes vs., 2:175
Uterine hypoplasia/agenesis, 2:20–25 subserosal
associated abnormalities, 2:22 endometriosis vs., 5:2–1
class I müllerian duct anomaly, 2:21 pedunculated
DES exposure vs., 2:51 ovarian transitional cell carcinoma vs.,
differential diagnosis, 2:21 5:110
genetics, 2:22 parasitic leiomyoma associated with, 2:81
Mayer-Rokitansky-Küster-Hauser (MRKH) tubal leiomyoma vs., 6:35
syndrome associated with, 2:21, 22 suppurative. See Pyomyoma.
Uterine infection. See Uterus, inflammation/ tubal leiomyoma associated with, 6:36
infection. uterine leiomyosarcoma vs., 2:121
Uterine leiomyoma, 2:66–71 with fatty degeneration, cystic adenomyosis vs.,
adenomyoma associated with, 2:200 2:203
adenomyoma vs., 2:199 with hemorrhagic degeneration, cystic
adenomyosis vs., 2:104 adenomyosis vs., 2:203
autoinfarction, uterine artery embolization vs., with hemorrhagic infarction, pyomyoma vs., 2:63
2:170 Uterine leiomyoma, degenerated, 2:72–79
benign metastasizing, 2:84–85 benign, lipomatous uterine tumors vs., 2:97
intravenous leiomyomatosis vs., 2:91 endometrial stromal sarcoma vs., 2:143
concomitant, lipomatous uterine tumors pyomyoma vs., 2:63
associated with, 2:98 sarcomatous, lipomatous uterine tumors vs., 2:97
degenerated. See Uterine leiomyoma, Uterine leiomyomatosis, diffuse, 2:86–89
degenerated. benign metastasizing leiomyoma associated with,
differential diagnosis, 2:68 2:85
diffuse. See Uterine leiomyomatosis, diffuse. differential diagnosis, 2:87
disseminated peritoneal leiomyomatosis intravenous leiomyomatosis vs., 2:91
associated with, 2:95 peritoneal, benign metastasizing leiomyoma
endocervical polyp vs., 3:13 associated with, 2:85
genetics, 2:68 Uterine leiomyomatosis, disseminated peritoneal,
genital lymphoma vs., 7:3 2:94–95
hemorrhagic degeneration, unicornuate uterus benign metastasizing leiomyoma associated with,
vs., 2:27 2:85
xxxi

INDEX
differential diagnosis, 2:95 sarcomas, other
INDEX
intravenous leiomyomatosis vs., 2:91 adenosarcoma vs., 2:111

Uterine leiomyomatosis, intravenous, 2:90–93 endometrial stromal sarcoma vs., 2:143
benign metastasizing leiomyoma associated with, uterine leiomyosarcoma vs., 2:121
2:85 Uterine procedure, pelvic inflammatory disease
differential diagnosis, 2:91 associated with, 6:8
disseminated peritoneal leiomyomatosis vs., 2:95 Uterine prolapse
endometrial stromal sarcoma vs., 2:143 clinical findings related to pelvic organ prolapse,
Uterine leiomyosarcoma, 2:120–123 8:70
degenerated leiomyoma vs., 2:74 grading, 8:82
differential diagnosis, 2:121 Uterine sarcoma. See Endometrial stromal sarcoma.
disseminated peritoneal leiomyomatosis vs., 2:95 Uterine sarcomas, other
intravenous leiomyomatosis vs., 2:91 adenosarcoma vs., 2:111
malignant mixed mesodermal tumor vs., 2:116 endometrial stromal sarcoma vs., 2:143
metastatic, benign metastasizing leiomyoma vs., uterine leiomyosarcoma vs., 2:121
2:85 Uterine septum, complete: septate uterus associated
parasitic leiomyoma vs., 2:81 with, 2:44
pyomyoma vs., 2:63 Uterine surgery, cystic adenomyosis associated with,
staging, grading, & classification, 2:122 2:204
uterine artery embolization vs., 2:170 Uterine synechiae. See Asherman syndrome,
uterine leiomyoma vs., 2:68 endometrial synechiae.
Uterine metastases. See Genital metastases. Uterine trauma, adenomyosis associated with, 2:194
Uterine neoplasms, 2:66–161 Uterine vascular malformation. See also Uterine
adenomyoma. See Uterine adenomyoma. arteriovenous malformation.
adenosarcoma, 2:110–113 pathology, 2:150
benign metastasizing leiomyoma, 2:84–85 treatment options, 2:153
differential diagnosis, 2:85 Uterocervical support components, 8:68
intravenous leiomyomatosis vs., 2:91 Uterovaginal agenesis. See Uterine hypoplasia/
degenerated leiomyoma. See Degenerated uterine agenesis.
leiomyoma. Uterovaginal septum, near complete resorption:
diffuse leiomyomatosis. See Diffuse uterine arcuate uterus associated with, 2:49
leiomyomatosis. Uterus
disseminated peritoneal leiomyomatosis adenomyoma. See Uterine adenomyoma.
benign metastasizing leiomyoma associated adenomyosis. See Uterine adenomyosis.
with, 2:85 anatomy, 2:2–15
differential diagnosis, 2:95 arteriovenous malformation. See Uterine
intravenous leiomyomatosis vs., 2:91 arteriovenous malformation.
endometrial carcinoma. See Endometrial congenital anomalies. See Uterus, congenital
carcinoma. anomalies.
endometrial hyperplasia. See Endometrial contraceptive device evaluation, 2:180–187
hyperplasia. cystic adenomyosis, 2:202–205
endometrial polyps. See Endometrial polyps. differential diagnosis, 2:203
endometrial stromal sarcoma. See Endometrial unicornuate uterus vs., 2:27
stromal sarcoma. endometrial atrophy, 2:14–15
gestational trophoblastic disease. See Gestational inflammation/infection. See Uterus,
trophoblastic disease. inflammation/infection.
intravenous leiomyomatosis. See Intravenous marked anteflexion, post cesarean section
uterine leiomyomatosis. appearance of uterus vs., 2:190
leiomyoma. See Uterine leiomyoma. neoplasms. See Uterine neoplasms.
leiomyoma vs., 2:68 obstructed
leiomyosarcoma. See Uterine leiomyosarcoma. secondary to malignancy, cervical stenosis vs.,
lipomatous uterine tumors, 2:96–99 3:9
malignant mixed mesodermal tumor. See secondary to mass effect, cervical stenosis vs.,
Malignant mixed mesodermal tumor, 3:9
uterine. post cesarean section appearance, 2:188–191
parasitic leiomyoma, 2:80–83 tamoxifen-induced changes. See Tamoxifen-
sarcoma. See Endometrial stromal sarcoma. induced changes.
uterine artery embolization imaging, 2:168–173
xxxii

INDEX
Uterus, congenital anomalies, 2:16–53 Vaginal agenesis
INDEX
arcuate uterus. See Arcuate uterus. androgen insensitivity syndrome vs., 7:15
bicornuate uterus. See Bicornuate uterus. with uterine hypoplasia
DES (diethylstilbestrol) exposure. See DES imperforate hymen vs., 4:15
(diethylstilbestrol) exposure. vaginal atresia vs., 4:11
hypoplasia/agenesis. See Uterine hypoplasia/ vaginal septa vs., 4:17
agenesis. Vaginal anatomy, 4:2–7
müllerian duct anomalies. See Müllerian duct anatomy imaging issues, 4:3–4
anomalies. axial MR, 4:6
obstructive, endometriosis associated with, 5:201 clinical issues, 4:4
septate uterus. See Septate uterus. CT, 4:7
unicornuate uterus. See Unicornuate uterus. embryology, 4:4
uterine cysts, 2:52–53 gross anatomy, 4:2
uterus didelphys. See Uterus didelphys. imaging anatomy, 4:3
Uterus didelphys, 2:32–37 sagittal graphic illustration, 4:5
associated abnormalities, 2:33 sagittal MR, 4:8
bicornuate uterus vs., 2:39 ultrasound, 4:7
class III müllerian duct anomaly, 2:33 Vaginal angiomyxoma, aggressive, 4:76–79
differential diagnosis, 2:33 Vaginal atresia, 4:10–13
septate uterus vs., 2:43 differential diagnosis, 4:11
unicornuate uterus vs., 2:27 imperforate hymen vs., 4:15
Uterus, inflammation/infection vaginal septa vs., 4:17
ascending infection, pyomyoma associated with, Vaginal carcinoma, 4:32–43
2:63 adenocarcinoma
Asherman syndrome, endometrial synechiae, general features, 4:36
2:54–57 gross pathology and surgical features, 4:36
DES exposure vs., 2:51 microscopic pathology, 4:36–37
differential diagnosis, 2:55 adenocarcinoma, endometrial, microscopic
endometritis, 2:58–61 pathology, 4:37
differential diagnosis, 2:59 adenocarcinoma, mesonephric, microscopic
endometrial hyperplasia vs., 2:107 pathology, 4:37
pyomyoma vs., 2:63 adenocarcinoma, mucinous, microscopic
pyomyoma, 2:62–65 pathology, 4:37
Uterus, treatment-related conditions associated diseases, abnormalities, 4:36
contraceptive device evaluation, 2:180–187 classification, 4:36
post cesarean section appearance, 2:188–191 clear cell
tamoxifen-induced changes, 2:174–179 DES exposure associated with, 2:51
Uterus, vascular disorders yolk sac tumor vs., 4:51
arteriovenous malformations. See Uterine clinical issues, 4:37–38
arteriovenous malformation. natural history and prognosis, 4:38
uterine artery embolization imaging, 2:168–173 presentation, 4:37–38
V
treatment options by stage, 4:38
foreign bodies vs., 4:104
genital lymphoma vs., 7:3
imaging findings, 4:37
Vaginal adenocarcinoma leiomyoma vs., 4:19
endometrioid, microscopic pathology, 4:37 leiomyosarcoma vs., 4:45
mesonephric, microscopic pathology, 4:37 melanoma vs., 4:73
mucinous, microscopic pathology, 4:37 overview, 4:36
pathology paraganglioma vs., 4:29
general features, 4:36 pathology, 4:36–37
gross pathology & surgical features, 4:36 general features, 4:36
microscopic pathology, 4:36–37 gross pathology and surgical features, 4:36
treatment options by stage, 4:38 microscopic pathology, 4:36–37
Vaginal adenosis, DES exposure associated with, routes of spread, 4:36
2:51 reporting checklist, 4:38
xxxiii

INDEX
squamous cell carcinoma genetics, 4:19
INDEX
general features, 4:36 genital lymphoma vs., 7:3

gross pathology and surgical features, 4:36 gross pathologic and surgical features, 4:19
microscopic pathology, 4:36 paraganglioma vs., 4:29
staging vaginal leiomyosarcoma vs., 4:45
AJCC Stages/Prognostic Groups, 4:32 Vaginal leiomyosarcoma, 4:44–45
(T), 4:32 differential diagnosis, 4:45
(N), 4:32 vaginal leiomyoma vs., 4:19
(M), 4:32 Vaginal lymphoma, paraganglioma vs., 4:29
imaging findings, 4:37 Vaginal melanoma, 4:72–75
metastases, organ frequency, 4:35 differential diagnosis, 4:73
nodal drainage, 4:35 genetics, 4:73
reporting checklist, 4:38 staging, grading, & classification, 4:73
restaging (imaging findings), 4:37 Vaginal metastases. See also Genital metastases.
T1, 4:34 paraganglioma vs., 4:29
T1: invasive squamous cell carcinoma, 4:33 vaginal melanoma vs., 4:73
T2, 4:34 Vaginal neoplasms
T3, 4:33, 34 adenocarcinoma. See Vaginal adenocarcinoma.
T4, 4:34 aggressive angiomyxoma, 4:76–79
Tis, 4:33 Bartholin gland adenocarcinoma, Bartholin cysts
staging (images), 4:39–43 vs., 4:88
local recurrence, 4:43 Bartholin gland carcinoma, 4:54–55
metastatic vaginal carcinoma, 4:43 bartholinitis vs., 4:91
stage I (T1 N0 M0), 4:39–40 differential diagnosis, 4:55
stage II (T2 N0 M0), 4:40 carcinoma. See Vaginal carcinoma.
stage IVA (T4 N0 M0), 4:42–43 embryonal rhabdomyosarcoma. See Vaginal
stage IVA (T4 N1 M0), 4:41 embryonal rhabdomyosarcoma.
Vaginal clear cell carcinoma leiomyoma. See Vaginal leiomyoma.
DES exposure associated with, 2:51 leiomyosarcoma, 4:44–45
yolk sac tumor vs., 4:51 differential diagnosis, 4:45
Vaginal clot, vaginal foreign bodies vs., 4:104 vaginal leiomyoma vs., 4:19
Vaginal congenital anomalies melanoma, 4:72–75
duplicated vagina, uterus didelphys associated differential diagnosis, 4:73
with, 2:33 staging, grading, & classification, 4:73
imperforate hymen. See Imperforate hymen. paraganglioma, 4:28–31
vaginal atresia, 4:10–13 yolk sac tumor, 4:50–53
imperforate hymen vs., 4:15 vaginal embryonal rhabdomyosarcoma vs.,
vaginal septa vs., 4:17 4:47
vaginal septa. See Vaginal septa. Vaginal paraganglioma, 4:28–31
Vaginal embryonal rhabdomyosarcoma, 4:46–49 Vaginal pheochromocytoma. See Vaginal
differential diagnosis, 4:47 paraganglioma.
paraganglioma vs., 4:29 Vaginal sarcoma, vaginal melanoma vs., 4:73
staging, grading, & classification, 4:47 Vaginal septa, 4:16–17
vaginal leiomyoma vs., 4:19 differential diagnosis, 4:17
yolk sac tumor vs., 4:51 longitudinal, bicornuate uterus associated with,
Vaginal fibroid. See Vaginal leiomyoma. 2:40
Vaginal fistula, 4:110–113 transverse
etiology, 4:112 bicornuate uterus associated with, 2:40
foreign bodies vs., 4:104 imperforate hymen vs., 4:15
Vaginal foreign bodies, 4:102–109 vaginal atresia vs., 4:11
Vaginal Gartner duct cysts. See Gartner duct cysts. Vaginal Skene’s gland. See Skene’s gland cyst.
Vaginal hemangioma, paraganglioma vs., 4:29 Vaginal support, normal
Vaginal intraepithelial neoplasia, vaginal carcinoma components, 8:68
associated with, 4:36 image interpretation, 8:81
Vaginal leiomyoma, 4:18–23 Vaginal support system defects, classifying, 8:81
xxxiv

INDEX
Vaginal urethral diverticulum. See Urethral gross pathology and surgical features, 4:63
INDEX
diverticulum. microscopic pathology, 4:63
Vaginal vault prolapse routes of spread, 4:62
image interpretation, 8:82 reporting checklist, 4:65
stages, 8:82 Skene’s gland cyst vs., 4:99
structural defects leading to pelvic organ staging
prolapse, 8:69 AJCC Stages/Prognostic Groups, 4:56
Vaginal wall prolapse (T), 4:56
anterior wall, 8:68–69 (N), 4:56
posterior wall, 8:69 (M), 4:56
Vaginal wall support, normal imaging findings, 4:63–64
anterior wall, 8:68 metastases, organ frequency, 4:61
posterior wall, 8:68 N1a, 4:60
Vaginal yolk sac tumor, 4:50–53 N1b, 4:60
differential diagnosis, 4:51 N2a, 4:60
vaginal embryonal rhabdomyosarcoma vs., 4:47 N2b, 4:60
Vaginitis emphysematosa, vaginal foreign bodies N2c, 4:61
vs., 4:104 N3, 4:61
Vascular malformation, uterine. See also Uterine reporting checklist, 4:65
arteriovenous malformation. restaging, imaging findings, 4:64
pathology, 2:150 T1a, 4:57, 59
treatment options, 2:153 T1b, 4:58, 59
Venous thromboembolism (Trousseau syndrome), T2, 4:59
ovarian endometrioid carcinoma associated T3, 4:58, 60
with, 5:100 Tis, 4:57
Ventral urethral ligaments, MR imaging, 8:61–62 staging (images), 4:66–69
Villoglandular adenocarcinoma, cervical, recurrence, 4:69
microscopic pathology, 3:30 stage IB (T1b N0 M0), 4:66
Vulvar anatomy stage II (T2 N0 M0), 4:66
anatomy imaging issues, 4:3–4 stage IIIA (T1b N1b M0), 4:66
clinical issues, 4:4 stage IIIB (T2 N2b M0), 4:66
CT, 4:9 stage IIIC (T2 N2c M0), 4:67–68
embryology, 4:4 stage IVA (T2 N3 M0), 4:69
graphic illustration, 4:5 stage IVA (T3 N0 M0), 4:69
gross anatomy, 4:2–3 Vulvar conditions, benign: vulvar leiomyosarcoma
imaging anatomy, 4:3 vs., 4:71
MR, 4:9 Vulvar cysts. See Bartholin cysts; Bartholinitis.
ultrasound, 4:9 Vulvar dystrophy, vulvar carcinoma associated with,
Vulvar angiomyofibroblastoma, aggressive 4:62, 63
angiomyxoma vs., 4:77 Vulvar endometriosis, hemangioma vs., 4:25
Vulvar angiomyxoma, aggressive, 4:76–79 Vulvar glandular neoplasms
Vulvar carcinoma, 4:56–69 Bartholin gland adenocarcinoma, Bartholin cysts
aggressive angiomyxoma vs., 4:77 vs., 4:88
Bartholin gland carcinoma vs., 4:55 Bartholin gland carcinoma, 4:54–55
bartholinitis vs., 4:91 bartholinitis vs., 4:91
classification, 4:62 differential diagnosis, 4:55
clinical issues, 4:64–65 Vulvar hemangioma, 4:24–27
natural history and prognosis, 4:64 Vulvar intraepithelial neoplasia, vulvar carcinoma
presentation, 4:64 associated with, 4:62
treatment options, 4:64–65 Vulvar leiomyosarcoma, 4:70–71
treatment options by stage, 4:65 Vulvar melanoma, 4:72–75
imaging findings, 4:63–64 differential diagnosis, 4:73
Merkel cell tumor vs., 4:81 genetics, 4:73
overview, 4:62 Merkel cell tumor vs., 4:81
pathology, 4:62–63 staging, grading, & classification, 4:73
etiology, 4:62–63 Vulvar Merkel cell tumor, 4:80–81
general features, 4:62–63 differential diagnosis, 4:81
genetics, 4:62 melanoma vs., 4:73
xxxv

INDEX
Vulvar metastases, vulvar melanoma vs., 4:73
INDEX
Vulvar squamous cell carcinoma, vulvar melanoma

vs., 4:73
Vulvar tumors, other malignant: vulvar
leiomyosarcoma vs., 4:71
W
Walthard cell nests, ovarian transitional cell
carcinoma associated with, 5:110
Wilms tumor 1 protein, malignant mixed
mesodermal tumor associated with, 2:116
Y
Yolk sac tumor, ovarian, 5:132–135
ovarian choriocarcinoma vs., 5:137
Yolk sac tumor, vaginal, 4:50–53
vaginal embryonal rhabdomyosarcoma vs., 4:47
xxxvi

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Shaaban Shaaban

MENIAS • REZVANI • TUBAY

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Christine O. Menias, MD Marc S. Tubay, MD

Maryam Rezvani, MD Rania Farouk El Sayed, MD, PhD

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DIAGNOSTIC IMAGING: GYNECOLOGY, SECOND EDITION ISBN: 978-1-931884-77-8

Copyright © 2015 by Elsevier. All rights reserved.

Publisher Cataloging-in-Publication Data

Diagnostic imaging. Gynecology / [edited by] Akram M. Shaaban.

International Standard Book Number: 978-1-931884-77-8

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I’d like to dedicate this book to all my former residents, fellows,

I wish to dedicate this to my teachers and mentors, for their generosity

To the awesome Amirsys pub team (Andrea, Angie, Arthur, Ashley,

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Oguz Akin, MD Nyree Griffin, MD, FRCR

Olga Hatsiopoulou, MD, FRCR

Marcia C. Javitt, MD, FACR

Ilse Castro-Aragon, MD Deborah Levine, MD, FACR

Director of Ob/Gyn Ultrasound

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Khashayar Rafatzand, MD, FRCPC

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We are pleased to present Diagnostic Diagnostic Imaging: Gynecology, second edition

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Art Direction and Design

Names you know. Content you trust.®

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SECTION 4: Vagina and Vulva

SECTION 6: Fallopian Tubes

SECTION 7: Multiorgan Disorders

SECTION 8: Pelvic Floor

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Uterus Benign Neoplasms

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Cervical Anatomy 3-2 Vaginal Paraganglioma 4-28

Infection/Inflammation Malignant Neoplasms

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