Unilateral primary ovarian leiomyoma in adolescent: a case report

Background Primary ovarian leiomyoma is a rare, usually small and incidentally detected neoplasm, clinically indistinguishable from subserous leiomyomas and ovarian fibromas, until histopathological confirmation. Case report We report a rare case of unilateral, ovarian leiomyoma that was not associated with uterine tumor in a 17-year-old woman. Trans abdominal ultrasonography and magnetic resonance imaging (MRI) revealed a pelvic mass (15 cm × 12 cm). Conclusion At laparotomy, unilateral salpingo-oophorectomy was performed and histologic examination revealed a leiomyoma arising primarily in the ovary.     

Screening for uterine tumours

The most prevalent uterine tumours are leiomyomas, which are benign and have a prevalence of about 50% at menopause. The incidence of endometrial cancer and uterine sarcomas is about 25 per 100,000 and 0.7 per 100,000, respectively. Reported risk factors for endometrial cancer are advanced age, unopposed oestrogen stimulation, late menopause, obesity, diabetes mellitus, nulliparity, feminising ovarian tumours, polycystic ovarian syndrome, tamoxifen and belonging to a hereditary non-polyposis colorectal cancer family. Unopposed oestrogen stimulation and tamoxifen have also been confirmed to induce uterine sarcomas. Cervical cytology, endometrial sampling and ultrasound have been proposed in the early diagnosis of endometrial cancer. No pathognomonic ultrasound, magnetic resonance imaging or computed tomography features are able to differentiate between a leiomyoma and a uterine sarcoma, and reliable serum markers for sarcomas are lacking. To date, mass screening for uterine malignancies is not feasible or effective.     

Clinical presentation and diagnosis of uterine sarcoma, including imaging

Uterine sarcomas are uncommon tumours from mesenchymal elements. They are thought to arise primarily from endometrial stroma and uterine muscle, respectively. When endometrial stroma undergoes malignant transformation, it might be accompanied by a malignant epithelial component. Thus, malignant mesenchymal uterine tumours comprise leiomyosarcoma, endometrial stromal sarcoma, undifferentiated uterine sarcoma and carcinosarcoma. In this chapter, we discusses preoperative presentation, diagnosis and current progress in different imaging modalities, including ultrasonography, computed tomography, magnetic resonance image and positron emission tomography scan. We summarise advances in new technology, which might improve preoperative detection and enhance referral to gynaecologic oncologists for optimal staging surgery and treatment.     

Magnetic Resonance Imaging of Benign and Malignant Adnexal Diseases: A Review

The authors describe the objectives of performing magnetic resonance imaging in the diagnosis of a variety of common and uncommon benign and malignant adnexal diseases. Depending on the clinical findings, the utility of magnetic resonance imaging is campared with ultrasound, computed tomography, laparoscopy, and surgery. The differentiating points between benign and malignant tumours are emphasized in detail. The classification of the ovarian tumours and the staging system of ooarian malignancy are revisited.     

Imaging malignant gynaecological conditions

Radiology continues to play an essential role in the management of malignant gynaecological conditions. Multiple imaging modalities are utilised to investigate suspected gynaecological malignancy including: ultrasound, computed tomography, magnetic resonance imaging and positron emission tomography/computed tomography. Each modality has a different role in diagnosis, staging, treatment selection and follow-up. This review discusses the different imaging modalities and their recommended roles in the imaging of malignant gynaecological disease. The imaging findings of common female pelvic pathology are discussed and illustrated.     

Imaging malignant gynaecological conditions

Radiology plays an essential role in the management of malignant gynaecological conditions. Multiple imaging modalities are utilized to investigate suspected gynaecological malignancy including: ultrasound, computed tomography, magnetic resonance imaging and positron emission tomography/computed tomography. Each modality has a different role in diagnosis, staging, treatment selection and follow-up. This review discusses the different imaging modalities and their recommended roles in the imaging of malignant gynaecological disease. The imaging findings of common female pelvic pathology are discussed and illustrated.     

Benefits and limitations of ultrasonographic evaluation of uterine adnexal lesions in early detection of ovarian cancer

Ovarian cancer is the most frequent cause of death from gynaecological malignancies in the Western world. Most cases of epithelial ovarian cancer are detected at late stages and the resultant overall five-year survival is poor. However, when epithelial ovarian cancer is detected with the disease confined to the ovary the prognosis is favorable. Transvaginal gray-scale ultrasonography and colour Doppler assessment of blood flow have been evaluated as methods to predict risk of malignancy in ovarian tumours. In order to reduce the number of unnecessary surgical procedures for uterine adnexal tumours, ultrasonomorphologic scoring systems have been developed, assigning numerical ultrasonographic parameters of the tumours. However, the positive predictive value of these scoring systems is low and this is due to the fact that the appearance of many benign ovarian lesions overlaps with that of malignant disease. In addition, some ovarian malignancies are ultrasonographically detected as simple cysts without exhibiting a complex morphology. Moreover, the cut-off size of uterine adnexal tumours for surgical intervention in the early detection of cancer is not yet well determined. The application of colour blood-flow imaging is very helpful in the detection of uterine adnexal malignancy because of the presence of neovascularization in malignant tumours. When gray-scale ultrasonography detects the presence of septum or papillary projections or solid components in uterine adnexal lesions and Doppler flow is present within these lesions malignancy is likely. However, the detection of vascularity within the papillary projection of a malignant tumour may not be detected when it is very small. When colour-flow imaging is used in premenopausal patients attention is needed to avoid confusion of luteal flow with flow of cystic lesions. Initial reports using pulsed Doppler ultrasonography showed high sensitivity and specificity in the detection of ovarian cancer when levels of the resistive index (RI) less than 0.4 and levels of the pulsatility index (PI) less than 1 were used. Subsequent studies have shown considerable overlap of RI and PI rates between benign and malignant uterine adnexal masses, suggesting that pulsed Doppler ultrasonography is not an independent indicator for malignancy. Serum CA-125 levels have been used in conjunction with ultrasonography to identify as many of the false-positive results in order to avoid unnecessary surgery. In postmenopausal women with a uterine adnexal mass the combination of physical examination with serum CA-125 levels and pelvic ultrasound scan seems to improve the sensitivity and specificity of predicting adnexal malignancies. In contrast, in premenopausal women the consideration of CA-125 levels with Doppler ultrasonographic findings might confuse the differential diagnosis of ovarian masses. In conclusion, accurate selection of patients with uterine adnexal tumours for surgical intervention is not provided by pelvic ultrasonography. Pelvic ultrasonography as a screening method for the early detetection of ovarian cancer should be probably limited to those women who are at increased risk for development of ovarian cancer and not in the general population.     

Imaging techniques for fibroid detection

Ultrasound imaging techniques, both transabdominal and transvaginal, are the most accurate and widely used imaging modalities in the detection and characterization of uterine leiomyomas. The diagnosis of these tumours may be enhanced using ultrasound-guided uterine biopsy and hysterosonography. Magnetic resonance imaging provides accurate imaging information, but its cost and lack of significant superiority over ultrasound have hitherto limited its use. Computerized tomography, plain X-ray, and hysterosalpingography have little to offer in the assessment of fibroids.     

CT and MRI of uterine lipoleiomyoma

Uterine lipoleiomyomas are rare tumors containing variable amounts of fat. Diganostic considerations usually include ovarian fatty tumors and benign and malignant degeneration in ordinary leiomyomas. A case in which a preoperative diagnosis was made using computed tomography (CT) and magnetic resonance imaging (MRI) is presented. The fatty nature of the lesion was demonstrated with CT and standard spin echo MRI and further supported using inversion recovery MRI. MRI also clearly depicted the intrauterine location of the tumor.     

CT and MRI of uterine lipoleiomyoma

Uterine lipoleiomyomas are rare tumors containing variable amounts of fat. Diganostic considerations usually include ovarian fatty tumors and benign and malignant degeneration in ordinary leiomyomas. A case in which a preoperative diagnosis was made using computed tomography (CT) and magnetic resonance imaging (MRI) is presented. The fatty nature of the lesion was demonstrated with CT and standard spin echo MRI and further supported using inversion recovery MRI. MRI also clearly depicted the intrauterine location of the tumor.     

Uterine inversion in association with uterine sarcoma: a case report with MRI findings and review of the literature

Non-puerperal uterine inversion due to uterine sarcomas represents a very rare event with no reliable estimate of frequency in the literature. Clinically, the diagnosis of inversion may be difficult, as far as imaging procedures are concerned, although ultrasonography may prove to be useful. However, some characteristics such as the indentation of the fundic area and a depressed longitudinal groove extending from the uterus to the center of the inverted portion are difficult to recognize. Moreover, there is no specific computed tomography feature accurate enough to aid in the differential diagnosis. Here, we report a case of uterine inversion due to Müllerian uterine adenosarcoma whose preoperative workup and diagnosis took advantage of the application of magnetic resonance imaging.     

Imaging benign gynaecological conditions

Radiology continues to play an essential role in the management of benign gynaecological conditions. Multiple imaging modalities are utilised to investigate benign conditions: ultrasound; computed tomography and magnetic resonance imaging. Each modality has a different role in diagnosis, treatment selection and follow-up. This review discusses the different imaging modalities and their recommended roles in the imaging benign gynaecological conditions. The imaging findings of common benign female pelvic pathology are discussed and illustrated.     

Imaging benign gynaecological conditions

Radiology plays an essential role in the management of benign gynaecological conditions and includes: ultrasound; computed tomography and magnetic resonance imaging. Each modality has a different role in diagnosis, treatment selection and follow-up. This review discusses the different imaging modalities, their recommended roles in the imaging and imaging findings of common female pelvic pathology.     

Puerperal pelvic thrombophlebitis: impact on diagnosis and treatment using x-ray computed tomography and magnetic resonance imaging

The clinical diagnosis of puerperal pelvic thrombophlebitis was confirmed by x-ray computed tomography in 11 women, and further documented in six by magnetic resonance imaging. Venous thrombi were demonstrated in ovarian, iliofemoral, and inferior vena caval vessels. In six women with ovarian vein involvement and no evidence of iliofemoral thrombophlebitis, resolution followed intravenous antimicrobial therapy alone, and in three of these, resolution was confirmed by x-ray tomography. In contrast, three of five women with symptomatic iliofemoral thrombophlebitis had a prolonged febrile course despite antimicrobial and heparin therapy. The clinical courses of these 11 women were consistent with the observation that pelvic thrombophlebitis is associated with pelvic infection. Disease manifested within a few days after parturition was more likely due to ovarian vein involvement, whereas disease with later onset of symptoms was more likely due to iliofemoral thrombosis, with or without vena caval extension. Through the use of x-ray computed tomography and magnetic resonance imaging, the natural course of pelvic thrombophlebitis can be better elucidated and therapeutic regimens more clearly evaluated.     

Imaging of the female pelvis

Recent advances in cross-sectional imaging have led to an increasingly important role for radiology in the management of gynaecological conditions. Multiple imaging modalities are utilized to investigate the female pelvis including: ultrasound; computed tomography; magnetic resonance imaging; and positron emission tomography/computed tomography. Each modality has a different role in screening, diagnosis, staging, treatment selection and follow-up. This review will discuss the various imaging techniques and recommended roles for each modality and how these modalities are best employed in the imaging of the female pelvis. The imaging findings of common female pelvic pathology are discussed and illustrated.     

Focused ultrasound treatment of uterine fibroid tumors: safety and feasibility of a noninvasive thermoablative technique

OBJECTIVE: The purpose of this study was to determine the safety and efficacy of focused ultrasound surgery with magnetic resonance imaging guidance for the noninvasive treatment of uterine leiomyomas. STUDY DESIGN: Fifty-five women with clinically significant uterine leiomyomas were treated. Pain and complications were assessed prospectively, and posttreatment magnetic resonance imaging was used to measure the treatment effects. Patients in three of the five centers underwent planned hysterectomy after treatment, which provided pathologic correlation of treatment. RESULTS: Seventy-six percent of the enrolled patients completed the full treatment session. All treatments were conducted in an outpatient setting with minimal discomfort for subjects and no major complications. Pathologic examination of the uterus confirmed that magnetic resonance imaging guidance provides the safe and accurate delivery of effective levels of thermal energy with a 3-fold increase in volume of histologically documented necrosis, compared with treatment volume (6.6 +/- 0.8 vs 18.4 +/- 3.9 mL, P <.005). CONCLUSION: Magnetic resonance imaging-guided focused ultrasound surgery appears to be a well-tolerated treatment for uterine leiomyomas.     

Imaging in ectopic pregnancy.

The various imaging techniques that have been used to establish the site of an early pregnancy are hysterosalpingography, ultrasonography, duplex Doppler flow studies, computed tomography and magnetic resonance imaging. Ultrasonography and Doppler flow studies have emerged as the most important imaging techniques in pregnancy. When used in conjunction with beta-human chorionic gonadotropin levels, they exhibit high sensitivity and specificity for ectopic pregnancy. Hysterosalpingography in pregnancy has been abandoned, while computed tomography and magnetic resonance imaging are indicated only rarely.     

Diagnosing fetal urinary tract abnormalities: benefits of MRI compared to ultrasonography

BACKGROUND: To compare antepartum ultrasonography with magnetic resonance imaging for prenatal diagnosis of malformations in the fetal urinary tract in high risk patients during the last trimester. MATERIALS AND METHODS: The study involved 22 women and 24 fetuses with either severe oligohydramnios or ultrasonographically or clinically suspected abnormality of urinary tract. Ultrasound examination was carried out with 5 MHz abdominal convex probe and magnetic resonance imaging with superconductive 1.5 T equipment. Postnatal findings were used as reference. RESULTS: Correct diagnosis of urinary tract anomaly was done in 15 fetuses on ultrasound and in 20 fetuses on magnetic resonance imaging. Both methods enabled correct diagnosis in 12, only ultrasound in three and only magnetic resonance imaging in eight fetuses. Both methods imaged equivocally in one case. The additional information by magnetic resonance imaging was gained from five fetuses out of 12 pregnancies with oligohydramnios and from three fetuses out of ten pregnancies with normal amount of amniotic fluid. CONCLUSIONS: MRI is a valuable additional method to ultrasonography of fetal urinary tract if resolution of ultrasound is impaired for reason of oligohydramnios or technical deterioration.     

Postpartum ovarian vein thrombosis: an unpredictable event: two case reports and review of the literature

Ovarian vein thrombosis (OVT) is a rare but serious postpartum complication that, in most cases, occurs in the right ovarian vein. Certain diagnosis, following clinical suspect because of lower quadrant tenderness and fever that alone does not respond to adequate broad-spectrum antibiotics, is now based on computed tomography (CT), although other imaging techniques, such as color Doppler ultrasonography and magnetic resonance (MR) imaging, are useful. Heparin and intravenous antibiotics are the mainstay of treatment so as to avoid laparotomy. We report on the management of two cases of postpartum OVT.     

Magnetic resonance spectroscopy features of uterine leiomyomas

OBJECTIVE: The purpose of this study is to investigate the in vivo magnetic resonance spectroscopy features of uterine leiomyomas using long echo time and to characterize the spectral patterns of these lesions. METHODS: We calculated metabolites in 15 patients with uterine leiomyomas and myometrium of 20 healthy control subjects using single-voxel proton MR spectroscopy (point resolved spectroscopy technique, TE:136 ms). Voxels were placed at the center of the uterine leiomyomas. The peak areas of creatine, choline, lipid and lactate were determined. The MR spectroscopy results of uterine leiomyomas were compared with the spectroscopy results obtained from the myometrium of healthy control subjects. RESULTS: The characteristically obtained signal was choline, which was detected not only in 14 of the 15 leiomyomas (93.3%) but also in 18 of the 20 myometrium of control subjects (90%). The lipid signals were determined in 9 of 15 patients with uterine leiomyomas (60%) and 8 of 20 control subjects (40%). The lactate signal was obtained from six of 15 patients with leiomyomas (40%) but only two of myometrium (10%). The creatine signal was obtained from 4 of 15 patients with leiomyomas (26.6%) and 5 of 20 myometrium (25%). Among the tested parameters only lactate peak was statistically significant (p < 0.05). CONCLUSION: Proton MR spectroscopic imaging may be helpful for the investigation of the underlying pathophysiology of uterine leiomyomas. The presence of lactate and lipid signals in the spectrum may be a useful indicator of metabolic pathway of uterine leiomyomas.