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Magnetic resonance imaging evaluation of non ovarian adnexal lesions
Magnetic Resonance Imaging Evaluation of Non Ovarian Adnexal Lesions Shrey K Thawait, Kiran Batra, Drew A. Torigian, Avneesh Chhabra, Atif Zaheer, Stephen I. Johnson PII: DOI: Reference:
S0899-7071(15)00211-9 doi: 10.1016/j.clinimag.2015.07.031 JCT 7891
To appear in:
Journal of Clinical Imaging
Received date: Revised date: Accepted date:
19 February 2014 17 July 2015 30 July 2015
Please cite this article as: Thawait Shrey K, Batra Kiran, Torigian Drew A., Chhabra Avneesh, Zaheer Atif, Johnson Stephen I., Magnetic Resonance Imaging Evaluation of Non Ovarian Adnexal Lesions, Journal of Clinical Imaging (2015), doi: 10.1016/j.clinimag.2015.07.031
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Title of the submission: Magnetic Resonance Imaging Evaluation of Non Ovarian Adnexal Lesions Abbreviated Title: MRI of Non Ovarian Adnexal Lesions Authors: Shrey K Thawait1,MD; Kiran Batra2, MD; Drew A. Torigian3, MD MA; Avneesh Chhabra2, MD; Atif Zaheer2, MD; Stephen I. Johnson2, MD 1 Department of Radiology, Yale University - Bridgeport Hospital, 267 Grant Street Bridgeport, CT 06610 2 Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD 21287 3 Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia PA 19104 Emails of authors: Shrey K Thawait: [email protected] Kiran Batra: [email protected] Drew A. Torigian: [email protected] Avneesh Chhabra: [email protected] Atif Zaheer: [email protected] Stephen Johnson [email protected]
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Corresponding author: Stephen Johnson, MD Department of Radiology Johns Hopkins Hospital 601 North Caroline Street Baltimore, Maryland 21287 Office: (504) 473-2866 Fax: (410) 955-9446 Email: [email protected] Conflict of interest: NONE. The authors declare that they have no conflict of interest. Abstract Differentiation of non-ovarian from ovarian lesions is a diagnostic challenge. MRI of the pelvis provides excellent tissue characterization and high contrast resolution, allowing for detailed evaluation of adnexal lesions. Salient MRI characteristics of predominantly cystic lesions and predominantly solid adnexal lesions are presented along with epidemiology and clinical presentation. Due to its excellent soft tissue resolution, MR may be able to characterize indeterminate adnexal masses and aid the radiologist to arrive at the correct diagnosis, thus positively affect patient management. Keywords: adnexal lesion; magnetic resonance imaging (MRI); para-ovarian cyst, peritoneal inclusion cyst; leiomyoma; fallopian tube carcinoma
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Introduction A wide array of pathologies may present as a non-ovarian adnexal lesion. Accurate
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differentiation of such lesions from ovarian lesions and accurate lesion characterization are
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important, as correct diagnosis is crucial to avoid treatment delay or unnecessary therapy (1). These lesions are usually first encountered with ultrasound however, frequently pelvic ultrasonography lacks the specificity and will not be covered in this review (2). MRI offers
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excellent tissue characterization due to high soft tissue contrast and can aid in the diagnosis of such pathologies when incompletely evaluated with pelvic ultrasonography (2). MRI also offers
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high spatial resolution and multiplanar imaging capability, such that differentiation between nonovarian and ovarian lesions is feasible. The presence of a normal appearing ipsilateral ovary
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essentially excludes the presence of an ovarian lesion, whereas lack of visualization of a normal ovary may indicate an ovarian or non-ovarian lesion origin. MRI characterization of a nonovarian adnexal lesion is based on its morphological, signal intensity, and enhancement
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characteristics (1). The purpose of this pictorial review is to discuss the key MRI imaging
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features and clinical highlights of the most common cystic and solid non-ovarian adnexal lesions. Normal Anatomy
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The ovarian fossae, where the ovaries are generally seen in nulliparous women, are shallow peritoneal depressions occupying the lateral aspects of the rectouterine space bilaterally, located
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posterior to the broad ligaments and anterior to the ureters and internal iliac arteries (3). Ovarian position may be quite variable depending on urinary bladder distention, uterine size, rectosigmoid distention and presence of a pelvic lesion (3). MRI Technique MRI of the female pelvis may be performed on a 1.5 or 3 Tesla magnet. Three Tesla imaging provides increased signal to noise and CNR to improve image resolution and shorter image time (4). Drawbacks of using higher magnetic field strength include increased magnetic susceptibility, chemical shift, and RF inhomogeneity (4). The exact MRI protocol is guided by the clinical setting and by the available MRI scanner. Typically, axial T1-weighted images without and with fat suppression are obtained in order to differentiate macroscopic fat (which has high signal intensity on T1-weighted images without fat suppression and low signal intensity on fat-
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suppressed T1-weighted images) from proteinaceous fluid or subacute hemorrhage (which have high T1-weighted signal intensity without or with fat suppression). In addition, multiplanar T2weighted images are also obtained, often with fat suppression in the coronal plane to demonstrate
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lesional internal architecture including cystic and solid components (Table 1), and to delineate
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the anatomical relationship of the lesion with respect to the ipsilateral ovary and other pelvic organs. They are also useful for visualization of the internal architecture of the uterus and cervix.
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Diffusion-weighted images [with associated apparent diffusion coefficient (ADC) parametric map images] may also be obtained for improved detection and characterization of pelvic
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pathology (2). Qualitative assessment of signal intensities on diffusion-weighted images has shown significant differences in benign and malignant pathology, with high signal intensity was
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observed more frequently in malignant lesions (5). The combination of diffusion-weighted images with conventional MRI has been shown to improve the staging of ovarian cancer and peritoneal metastases. While ADC values for differentiating benign and malignant pathologies
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has widely varied among institutions for certain diseases such as cervical cancer, other entities such as peritoneal implants demonstrate restricted diffusion on DWI images with associated
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ADC values (5,6,7). Multiplanar fat-suppressed T1-weighted images after administration of Intravenous Gadolinium Based Contrast Agent (IV GBCA) are also obtained when possible in
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order to detect solid tissue components, peritoneal extension of disease, and vascular involvement. Please note, however, that IV GBCA is not administered to women who are
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pregnant or suspected to be pregnant. MRI was conducted for all patients by means of a 1.5-T or 3T system (Magnetom Symphony, Siemens, Erlangen, Germany) with the manufacturer's body and spine array coils. The entire liver was imaged in the transverse plane. First, we obtained axial T2 images through the entire pelvis (repetition time (TR)/echo time (TE): 5700/101; flip angle: 150°; slice thickness: 6 mm; matrix: 180 × 320) followed by T1 images without fat suppresion (repetition time (TR)/echo time (TE): 546/12; flip angle: 60°; slice thickness: 6 mm; matrix: 154 × 320) and T2 spacial coronal images (repetition time(TR)/echo time (TE): 1400/163; flip angle 60°; slice thickness: 12 mm; matrix: 154 × 320). DWI images (repetition time (TR)/echo time (TE): 3700/82; flip angle: 70°; slice thickness: 6 mm; matrix: 154 × 320). Sagittal VIBE (repetition time (TR)/echo time (TE): 10.2/4.85; flip angle: 70°; slice thickness: 4 mm; matrix: 154 × 320). Axial VIBE DWI images (repetition time (TR)/echo time (TE): 9.95/4.73; flip angle: 70°; slice thickness: 4
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mm; matrix: 154 × 320). Post contrast images (repetition time (TR)/echo time (TE): 9.95/4.73;
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flip angle: 70°; slice thickness: 4 mm; matrix: 154 × 320).
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Tubo-ovarian Abscess (TOA)
TOA typically presents as a complex lesion that involves the fallopian tube and/or ovary (8) and
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is the most common type of pelvic abscess in women of reproductive age (8) . In patients presenting with clinical symptoms of pelvic inflammatory disease, the presence of an adnexal
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lesion, age greater than 42 years and elevated erythrocyte sedimentation rate > 50 mm/hour (normal 0-10mm/hour) have been shown to be the best predictors of TOA (9). With widespread
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use of the broad-spectrum antibiotics, conservative treatment of TOA is usually successful (10). On MRI, TOA typically appears as a complex cystic lesion with internal septations, fluid-fluid or fluid-debris levels, and a thickened rim of 5 mm or thicker (11). A tubular fluid-filled structure
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due to pyosalpinx is also often seen. Low signal intensity foci of non-dependent gas may also be seen on T1-weighted and T2-weighted images, and the fluid contents has variable signal
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intensity depending on the presence and concentration of proteinaceous and cellular material, but is often hypointense on T1-weighted images and hyperintense on T2-weighted images (Fig 1)
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(10). Following administration of IV GBCA, enhancement of the septa and walls may be noted (10). Secondary findings include edema and inflammation of surrounding tissues with associated
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increased T2-weighted signal intensity and enhancement involving the mesenteric and omental fat, peritoneal thickening and enhancement, and pelvic organs.
Ectopic Pregnancy Implantation of the blastocyst at any site outside of the endometrium is termed ectopic pregnancy. Adhesions and scarring from prior inflammation lead to delayed tubal transit of embryo and prevent implantation in the endometrium. Several predisposing risk factors have been identified, such as previous ectopic pregnancy, previous tubal surgery, pelvic inflammatory disease, infertility, and smoking (12,13). The most common location for ectopic pregnancy is the fallopian tube (14). Levels of serum beta human chorionic gonadotropin are usually abnormally
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elevated (15). Although ultrasonography is the primary modality for the diagnosis of ectopic pregnancy, MRI can be helpful in equivocal cases, especially with presence of an interstitial or abdominal ectopic pregnancy. On MRI, a heterogeneous cystic lesion with a thickened wall and
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variably increased T1-weighted signal intensity components (due to subacute hemorrhage) and
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variably decreased T2-weighted signal intensity components (due to acute or subacute hemorrhage) may be seen (Fig 2). Additional findings such as hematosalpinx and
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hemoperitoneum may also be present (14,15).
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Para-ovarian Cyst
The para-ovarian (or paratubal) cyst arises within the broad ligament as a remnant of the Wolffian or Mullerian ducts usually adjacent to the ovary. This is most common in women in
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the 3rd-4th decades of life (16), accounts for 10-20% of adnexal lesions and may be bilateral or multiple (17). A paraovarian cyst does not show cyclical change whereas an ovarian cyst does.
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Most paraovarian cysts are benign. Predictors for malignancy include size over 5 cm, internal papillary excrescences and occurrence in reproductive-age women (18,19). On MRI, para-ovarian
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cysts are round or ovoid cystic lesions that are separate from the ipsilateral ovary (Fig 3), have thin walls with no or minimal enhancement, and contain simple fluid with low T1-weighted
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signal intensity and very high T2-weighted signal intensity relative to skeletal muscle (20). Hemorrhage within the cyst may lead to variably increased T1-weighted signal intensity and
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variably decreased T2-weighted signal intensity, and wall thickening or internal septations may also be present (Fig 3). Demonstration of enhancing soft tissue component after IV GBCA is worrisome for neoplasm. Para-ovarian cysts may also lead to ovarian torsion or rarely isolated tubal torsion (21) (Fig 4). Peritoneal Inclusion Cyst Localized peritoneal fluid contained by mesothelial lined adhesion is termed peritoneal inclusion cyst. It is commonly seen in premenopausal women with functioning ovaries and pelvic adhesions (22). Other predisposing factors include prior abdominal surgery, trauma, pelvic inflammatory disease, and endometriosis. On MRI, peritoneal inclusion cysts have low T1weighted signal intensity and very high T2-weighted signal intensity of simple fluid. Peritoneal inclusion cysts may be unilocular or septated, typically have thin minimally enhancing walls,
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have ill-defined borders defined by the peritoneal cavity, and abut and often surround one or both ovaries which appear normal (Fig 5). Occasionally, high signal intensity on T1-weighted images
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may be seen due to presence of proteinaceous fluid or hemorrhage (23).
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Hydrosalpinx / Hematosalpinx / Pyosalpinx
Depending on the cause of the obstruction, serous fluid, hemorrhage, or pus may accumulate
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within the fallopian tube resulting in distention, termed as hydrosalpinx, hematosalpinx, or pyosalpinx, respectively (24). Hydrosalpinx and pyosalpinx are commonly seen in women with
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pelvic inflammatory disease. Pyosalpinx is often bilateral and is associated with inflammatory changes such as edema, thickening, and enhancement of the tubal wall and surrounding pelvic
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tissues. Associated small bowel adynamic ileus or obstruction may also be seen. Hematosalpinx in the setting of endometriosis may be unilateral or bilateral. Other causes may include trauma, ectopic pregnancy, or malignancy (24). The distended fallopian tube usually assumes a tubular C-
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or S- shape, often with intraluminal mucosal folds similar to the spokes on a cogwheel, and is best visualized using multiplanar T2-weighted images (25). Simple fluid in a dilated fallopian
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tube shows low signal intensity on T1-weighted images and very high signal intensity T2weighted images (Fig 6). Hemorrhagic or proteinaceous fluid may have high signal intensity on
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T1-weighted images and variable signal intensity on T2-weighted images depending upon the age of hemorrhage (Fig 7). Fallopian tube carcinoma, although rare, should be suspected when
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nodular or solid enhancing components are present (24). Associated restriction of diffusion may also be seen on diffusion-weighted images. Other findings including lymphadenopathy or distant metastatic disease may also be encountered.
Pelvic Congestion Syndrome / Pelvic Varices Pelvic congestion syndrome is a common etiology of chronic pelvic pain, and is thought to have a multifactorial pathogenesis. Risk factors may include multiple prior pregnancies, a history of varicose veins, prior pelvic surgery, a retroverted uterus, and hormonal influences. Multiparous women of reproductive age are generally affected and complain of deep dull pelvic ache lasting > 6 months that is made worse by activities that increase intra-abdominal pressure (26). Pelvic congestion syndrome may be termed as primary, if no anatomic cause of venous obstruction is
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present. Secondary pelvic congestion syndrome may be caused by compression of the ovarian veins by a retroaortic left renal vein, the superior mesenteric artery (Nutcracker phenomenon), or as a component of iliofemoral deep venous thrombosis in May–Thurner syndrome (27). On
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MRI, pelvic varices appear as serpentine signal voids on non-contrast T1-weighted and T2-
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weighted images, although they may alternatively have increased signal intensity when there is slow blood flow. Pelvic varices demonstrate venous phase enhancement on T1-weighted images
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after contrast administration (Fig 8), and may be seen in the periuterine, periovarian, and/or perivaginal locations either unilaterally or bilaterally (28). Dilation of one or both ovarian veins
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to > 6 mm in diameter may also be seen in the setting of pelvic congestion syndrome. Furthermore, time resolved magnetic resonance venography may also be useful to depict
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retrograde flow in the dilated ovarian vein or veins filling the varices (29,30). However, it should be noted that presence of dilated gonadal veins and pelvic varices may be seen in asymptomatic women, particularly in those who have had prior pregnancy, and therefore the diagnosis of pelvic
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congestion syndrome can only be made definitively when a clinical history of chronic pelvic pain is also present.
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Tarlov Cyst / Perineural Sacral Cyst
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The estimated prevalence of Tarlov cysts is 5- 9% in the adult population (31). Dilated prominent nerve sleeves of spinal nerve roots produce these lesions (32). The most common location is at
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S2 and S3 levels. On MRI, Tarlov cysts follow the signal intensity characteristics of simple fluid with low signal on T1-weighted images and a very high signal on T2-weighted images (31). They are typically located in the sacral spinal canal and/or neural foramina, and can occasionally extend anteriorly into the pelvis, mimicking other pelvic or adnexal cystic lesions (Fig 9). Scalloping of the adjacent bone with an intact cortex, sacral canal widening, and neural foraminal enlargement may also be seen. However, no solid enhancing components are seen. Appendiceal Mucocele A mucocele of the appendix may uncommonly mimic an adnexal lesion and should be considered in patients with unexplained right lower quadrant abdominal pain (33,34). Abnormal mucus accumulation in the lumen of the appendix with luminal dilation leads to an appendiceal mucocele. The pathogenesis is related to obstruction of the proximal lumen or appendiceal
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orifice, and the most common etiologies include mucinous cystadenomas, mucosal hyperplasia, mucinous cystadenocarcinomas, and retention cysts (35). This entity is more commonly seen in middle aged women with a reported prevalence of 0.5-1% among patients undergoing
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appendectomy (36) and can mimic acute appendicitis. The other manifestations include
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asymptomatic palpable mass, intussusception, gastrointestinal bleeding, ureteral obstruction or hematuria, and abdominal distention from mucocele rupture, resulting in mucinous ascites
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(which is termed pseudomyxoma peritonei only when an appendiceal adenoma is the underlying lesion). On MRI, a well-defined tubular thin-walled cystic lesion, sometimes with invagination
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into the cecum, with rim enhancement is typically seen (37). The internal fluid typically has intermediate-high T1-weighted signal intensity and high T2-weighted signal intensity (Fig 10)
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(38). Focal enhancing nodules may also be seen, suggestive of mucinous cystadenoma or
cystadenocarcinoma. Associated pelvic lymphadenopathy or distant metastatic disease may be seen in the case of the latter (39). If there has been mucocele rupture, then complex loculated
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ascites is seen, typically with scalloping of adjacent parenchymal organs. Internal septations, peritoneal thickening and enhancement, enhancing nodules, and omental caking may also be
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Bladder Diverticulum
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seen.
An outpouching of bladder urothelium through the muscularis propria of the bladder wall
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constitutes a bladder diverticulum and may be congenital or acquired. Congenital diverticula are believed to form as a result of insufficient support of muscle at the ureterovesical junction (40). Boys are commonly affected and the presentation is at an age younger than 10 (40); hence, the congenital diverticulum is not usually confused with an adnexal lesion. An acquired diverticulum is more likely to mimic an adnexal lesion in women, although uncommon (41). When multiple diverticula are present, they are more commonly acquired. Bladder diverticula may also be seen in syndromes such as Ehlers-Danlos syndrome (42) and Menkes disease (43). On MRI, bladder diverticula have signal intensity similar to urine in the bladder on all pulse sequences, have thin walls, and communicate with the bladder lumen (Fig. 11). Calculi and enhancing malignant tumors may be present, with the former demonstrating low signal intensity on T1-weighted and T2-weighted images and no enhancement, and the latter demonstrating nodular enhancing components. Associated wall thickening may also be present.
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Uterine Leiomyoma Uterine leiomyoma is a benign, smooth muscle tumor which is the most common gynecologic
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tumor in the United States, and is clinically apparent in up to 25% of women (44). An exophytic
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or pedunculated uterine leiomyoma may simulate an adnexal mass. MRI establishes the myometrial origin of the lesion by demonstrating splaying of the uterine serosa or myometrium and absence of an intervening fat plane between the lesion and the uterus (45). On MRI,
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leiomyomas are typically sharply marginated with low- intermediate T1-weighted signal intensity and low T2-weighted signal intensity and demonstrate enhancement (46). However,
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presence of degeneration may lead to increased T1-weighted signal intensity, due to subacute hemorrhage or fatty change, or increased T2-weighted signal intensity without enhancement due
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to cystic/necrotic change (47,48). Vessels located between the uterus and the exophytic leiomyoma are typically seen as curvilinear or tortuous signal voids with venous phase enhancement (Fig 12). This finding, called the "bridging vessel sign", is present in up to 80% of
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cases and confirms a uterine origin of the lesion (49).
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Endometriosis
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Endometriosis has an estimated prevalence of 5–20% and affects women of reproductive age (50,51). The presence of functional endometrial glands and stroma outside the uterine cavity in
this disease may or may not be symptomatic. Chronic pelvic pain, dysmenorrhea and deep
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dyspareunia are the most common symptoms (52). The implant size may vary from microscopic endometriotic foci to large cysts (endometriomas). The sensitivity and specificity of MRI for the diagnosis of endometrioma are greater than 90% (53). On MRI, the signal characteristics may vary according to the age of hemorrhage, resulting in a mixed spectrum of appearances (54). However, characteristic MR imaging features of an endometrioma include an adnexal or ovarian lesion with high signal intensity on T1-weighted images and low signal intensity "shading" on T2-weighted images, without solid enhancing components (Fig 13) (55,56). Bilaterality and multiplicity of lesions also favor the diagnosis of endometriosis, and hydrosalpinges or hematosalpinges (Fig 7) may be present as well. The accuracy of MRI for detection of endometriomas is further increased by using fat-suppressed T1-weighted images (57). Fibrotic endometriosis appears as ill-defined low signal intensity lesions on T1-weighted and T2weighted images that enhance and occasionally contain high T1-weighted signal intensity
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hemorrhagic foci. They are seen in the pelvic peritoneal space, and can involve the cul-de-sac, uterosacral ligaments, broad ligaments, uterine wall, cervical wall, vaginal fornices, ureters, urinary bladder wall, bowel wall, body wall, and abdominal peritoneal cavity. Bowel obstruction
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or hydroureter may be visualized when there is bowel or ureteral obstruction, respectively. Fallopian Tube Carcinoma
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Fallopian tube carcinoma is rare, constituting 0.3 – 1% of all gynecological cancers (58). Presentation is nonspecific with vaginal bleeding being the most common presentation (59).
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Imaging findings pertain to the presence of a mass within the fallopian tube (Fig 14). On MRI, an adnexal cystic structure with low signal intensity on T1-weighted images and very high signal
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intensity on T2-weighted images, representing the dilated fallopian tube, is typically seen in association with wall thickening, enhancing mural nodules, or a solid enhancing mass that has slightly high T2-weighted signal intensity relative to skeletal muscle (60). Associated pelvic
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lymphadenopathy or distant metastatic disease may also be seen.
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Pelvic Hematoma
Pelvic hematoma may be seen in various clinical scenarios, and is common after surgery or
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trauma (61). On MRI, acute components of hemorrhage typically have low signal intensity on T1-weighted and T2-weighted images, whereas subacute components of hemorrhage have high
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signal intensity onT1-weighted images and variable signal intensity on T2-weighted images. Chronic components of hemorrhage will have very low signal intensity on T1-weighted and T2weighted images due to hemosiderin deposition (Fig 15). The "concentric ring sign" may also be seen, which is comprised of an inner peripheral rim of high T1-weighted signal intensity subacute hemorrhage and an outer peripheral rim of very low signal intensity chronic hemorrhage. Fluid-fluid levels and septations may also be present. However, no solid enhancing components are seen unless an underlying neoplasm is also present. If active hemorrhage is present, a focus or jet of extraluminal high signal intensity contrast material may be seen on postcontrast T1-weighted images. On serial imaging, hematomas will generally decrease in size and frequently resolve. Retrorectal developmental cyst
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The retrorectal space is a potential space between the posterior wall of the rectum anteriorly and the sacrum posteriorly (62). Tumors occurring in this space are extremely rare (63). Congenital lesions account for about half of all tumors and epidermoid, dermoid, developmental cysts (Fig
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16), and teratomas are the commonest (61). A dermoid cyst is more likely if MRI confirms the
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presence of fat content on fat-saturated images (Fig 17). MRI features such as smooth wellcircumscribed margins without any invasion may be seen with benign tumors while a
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heterogeneous solid tumor with an irregular / invasive margins, is more like to be malignant (64).
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Congenital uterine anomalies
The association between unicornuate uterus and renal anomalies such as agenesis has been well
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described (65,66). Abnormal or failed development of one of the paired müllerian ducts results in unicornuate uterus (67). A rudimentary horn may be present, which could be noncavitary, cavitary and non-communicating (Fig 18), or cavitary and communicating. Ultrasonography can
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be challenging in these cases due to atypical morphology of the uterus, and especially if echogenic endometrium within the rudimentary horn is absent (68). MRI is the best imaging
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technique to identify the rudimentary horn variant and to evaluate for the presence of associated
Pelvic Lymphocele
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renal anomalies (67).
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Pelvic lymphocele is a loculated fluid collection without an epithelial lining that develops following injury to lymphatic structures, most commonly from prior surgery or trauma. A lymphocele may develop in a significant proportion of post-operative cases of pelvic lymphadenectomy (69), and may cause symptoms due to secondary infection or mass effect upon adjacent structures (70). On MRI, lymphoceles typically appear as thin-walled cystic lesions with low T1-weighted and very high T2-weighted signal intensity similar to simple fluid without solid enhancing components (Fig 19). Subjacent susceptibility artifact on in-phase T1-weighted images due to surgical clips is frequently visualized, and internal septations may sometimes also be seen. However, solid enhancing components are not visualized. Pelvic Metastasis
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The most common primary tumors that spread to the pelvis are lymphoma and carcinomas of the breast, colon, and lung (71). On MRI, pelvic metastases generally demonstrate low-intermediate signal intensity on T1-weighted images and slightly high signal intensity on T2-weighted images
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relative to skeletal muscle, have restricted diffusion on diffusion-weighted images, and enhance
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(Fig 20). Presence of subacute hemorrhage may lead to increased T1-weighted signal intensity components, and presence of cystic/necrotic change leads to increased T2-weighted signal
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intensity components that do not enhancement (72). Associated pelvic lymphadenopathy or distant metastatic disease may also be seen.
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Conclusion
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MRI is useful in the detection and characterization of the non-ovarian adnexal lesions. After identification of a lesion as separate from the ovary and review of relevant clinical and laboratory based information about the patient, the next step is to assess its imaging features. The
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margins, shape, internal architecture, signal intensity characteristics, enhancement characteristics, and presence or absence of change in size and appearance since prior imaging all
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provide important clues on MRI to the most likely diagnosis (Fig 21, 22). While MRI does have limitations of cost and availability, MRI is useful to detect and characterize the indeterminate
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non-ovarian adnexal lesions and aid in guiding appropriate patient management.
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Figure Legends:
Fig. 1 Pyosalpinges (bilateral) and left tubo-ovarian abscess (TOA). 47 year-old-woman with
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abdominal pain, nausea and vomiting. (a) Axial T2-weighted and (b) Coronal post- IV GBCA
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T1-weighted images show dilated fluid filled tubular structures with decreased T2-weighted signal intensity (*) in adnexa representing bilateral pyosalpinges. Tubo-ovarian abscess is seen
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as a septated adnexal cystic lesion (arrows) adjacent to the left fallopian tube Fig. 2 Interstitial (cornual) ectopic pregnancy. 35 year-old-woman with previous history of
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ectopic pregnancies presents with amenorrhea, 1st trimester bleeding and severe pelvic pain. (a)
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Axial T1-weighted and (b) Axial T2-weighted images show thick-walled complex cystic lesion
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(arrows) in right adnexa in uterine cornu / interstitial portion of fallopian tube without intrauterine gestational sac seen in endometrial canal, compatible with cornual ectopic pregnancy. The right ovary is seen separately (*) Fig. 3 Para-ovarian cyst. 28 year-old-woman with infertility. (a) Axial T2-weighted and (b) Coronal T2-weighted image with fat suppression show small unilocular cyst (thick arrows) with very high signal intensity within the left adnexa. The left ovary (long arrows) is seen separately. Note arcuate configuration of uterus on axial image (curved arrow) Fig. 4 Isolated tubal torsion. 28 year-old-woman presented with right lower quadrant pain. Urine and serum pregnancy tests were negative. (a) Axial T2-weighted image shows a 4 cm right
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para-ovarian unilocular cyst with very high signal intensity (arrow). Note the normal right ovary anterior to the cyst with a dominant follicle (asterisk) (b) Coronal T2-weighted image shows a
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swirling appearance of the right fallopian tube (arrow). Surgical exploration revealed a normal
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right ovary with a 4-cm-size right fallopian tube and paratubal cyst complex which had torsed on itself three times. During surgery the right fallopian tube torsion was reduced after which viable
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adnexa was confirmed. Paraovarian cystectomy was then performed
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Fig. 5 Peritoneal inclusion cyst . 40 year-old-woman with pelvic pain 7 years after
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hysterectomy. (a) Axial T2-weighted image reveals a thin-walled unilocular cystic lesion (*) in right adnexa that partially surrounds the right ovary (arrow) and conforms to the shape of the
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peritoneal cavity. (b) Axial post IV GBCA T1-weighted image does not show any solid enhancing component. Right ovary (arrow) is again seen
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Fig. 6 Hydrosalpinx. 66 year-old-woman with history of breast carcinoma. (a) Axial T1-
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weighted, (b) Axial T2-weighted and (c) Sagittal T2-weighted images reveal a dilated fluid-filled
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tubular cystic structure (arrows) in right adnexa Fig. 7 Hematosalpinges (bilateral). 35 year-old-woman with history of chronic pelvic pain and endometriosis. (a) Axial T1-weighted and (b) Axial T2-weighted images show dilated tubular structures (*) in adnexae. Note the increased T1-weighted and decreased T2-weighted signal intensity on the left, consistent with hemorrhagic fluid. On the right side an area of increased T1 signal intensity is noted (arrow), consistent with subacute hemorrhage Fig. 8 Pelvic congestion syndrome. 48 year-old-woman with chronic pelvic and vaginal pain. (a) Coronal post IV GBCA Maximum Intensity Projection (MIP) T1-weighted image and (b)
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Axial post IV GBCA T1-weighted images show dilated enhancing left ovarian vein and periuterine varices (arrows)
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Fig. 9 Tarlov cysts. 46 year-old-woman with history of irregular menses. (a) Axial T1-weighted and (b) Coronal T2-weighted image with fat suppression shows a dilated tubular cystic lesion
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(short arrows) in a right sacral foramen entering the pelvis in a right adnexal location. Note
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expansion of the right sacral foramen (*) and the separate right ovary (long arrow in a) Fig. 10 Appendiceal mucocele. 71 year-old-woman with right lower quadrant abdominal pain.
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(a), and (b) Sequential Axial T2-weighted images demonstrate dilated blind-ending tubular cystic lesion (arrows) originating from cecal base (white circle) (c) Axial post IV GBCA T1-
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weighted image with fat suppression shows minimal peripheral rim enhancement.
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Fig. 11 Bladder Diverticulum. 66 year old male with urinary retention. (a) Axial T2 images of the pelvis and (b) coronal T2 images of the pelvis demonstrate a small outpouching of the
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bladder, continuous with the bladder lumen, with a thin wall.
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Fig. 12 Pedunculated uterine leiomyoma. 43 year-old-woman with history of pelvic mass. (a) Axial T1-weighted image and (b) Axial post IV GBCA T1-weighted image with fat suppression show a large pedunculated low-intermediate signal intensity right adnexal mass (*) arising from the uterus (U). This is confirmed by the “bridging vessel sign” which is seen as serpentine flow voids in (a) between mass and uterus which demonstrate enhancement in (b) (long arrow). The right ovary was seen separately (not shown) Fig. 13 Endometriosis. 37 year-old-woman with history of pelvic inflammatory disease. (a) Axial T1-weighted image and,(b) Axial T2-weighted images show a dilated fluid-filled thickwalled tubular structure (*) in right adnexa, consistent with hydrosalpinx and chronic salpingitis.
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Several cystic structures are also seen (thick short arrows) in left adnexa with high T1-weighted signal intensity and low T2-weighted signal intensity, consistent with endometriomas. The right
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ovary is seen separately (long thin arrow) Fig. 14 Fallopian tube carcinoma. 60 year-old-woman with pelvic mass on prior
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ultrasonography. (a) Axial and (b) Sagittal T2-weighted images show heterogeneous solid adnexal mass (M), centered within a dilated tubular fluid-filled left fallopian tube (arrow) and
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extending posterior to uterus (U)
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Fig. 15 Pelvic Hematoma. 46-year-old-woman who underwent hysterectomy for leiomyosarcoma 8 months ago now presents with pelvic pain. (a) Axial T1-weighted image with
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fat suppression shows several rounded lesions in the pelvis with inner peripheral rim of high signal intensity (thick white arrow) and outer peripheral rim of very low signal intensity (thin
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white arrow), consistent with the "concentric rim sign" which is characteristic of subacute
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hematoma. (b) Axial T2-weighted image shows lesions with central high signal intensity (thick
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white arrows) and peripheral very low signal intensity (thin white arrow). (c) Axial contrastenhanced T1-weighted image with fat suppression shows lack of enhancement of the lesions Fig. 16 Congenital retrorectal developmental cyst. 38 year-old-woman presents with intermittent deep pelvic pain for several months. (a) Axial T2-weighted image and (b) Axial T2-weighted image with fat saturation show a well circumscribed mass in the retrorectal area (arrows). Note the smooth margins. The cystic portions appear T2 hyperintense (curved arrow). (c) Axial T1weighted image with fat saturation shows the cystic portions within this mass to be T1 hypointense (curved arrow). (d) Axial T1-weighted image after IV GBCA with fat saturation shows enhancement (arrow). Note that the cystic components do not enhance (curved arrow).
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The rectum has been displaced laterally (labeled as R) and the uterus is seen anteriorly (labeled as U). Biopsy showed fragments of benign fibromuscular tissue focally lined by simple columnar
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and metaplastic squamous epithelium, consistent with a retrorectal developmental cyst. Note the
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absence of fat signal within the lesion, which would have favored a dermoid cyst
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Fig. 17 Dermoid cyst. 36 year-old-woman presents with pelvic pain. (a) Axial T1-weighted without fat saturation show a well defined mass adjacent to the rectum (arrows). Note the smooth
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margins. A large portion appears T1 hyperintense (curved arrow). (b) Axial T1-weighted image
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with fat saturation shows the fat component to be hypointense (curved arrow). The presence of fat makes dermoid cyst as the most likely diagnosis. Note the relationship of this dermoid cyst
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with the rectum (labeled as R) and the uterus (labeled as U) Fig. 18 Unicornuate uterus with a non-communicating rudimentary uterine horn. 34 year-old-
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woman presents with pelvic pain. (a) Axial T2-weighted image shows rudimentary horn on the
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left side (thin arrow) that does not communicate with the uterine cavity (thick arrow). Note
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central low signal intensity within rudimentary horn (curved arrow) along with normal myometrial tissue layers. The inner myometrium is seen with low signal intensity (black arrowhead), outer myometrium with high signal intensity (chevron). (b) Axial T1-weighted image with fat suppression shows central high signal intensity (curved arrow) in keeping with subacute hemorrhage within rudimentary horn endometrial canal Fig 19 Lymphocele. 75 year old female status post lymph node dissection secondary to prostate cancer. Coronal T2 images demonstrate with a left adnexal fluid collection demonstrating hyper T2 signal with a small amount of layering debris.
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Fig 20 Pelvic metastasis. 63 year old female with metastatic endometrial carcinoma. (a) Axial T2 fat saturation image demonstrates multiple cystic pelvic collections, the more anterior
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collection demonstrates nodularity. (b) Axial T1 fat saturated image after the administration of
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intravenous gadolinium contrast demonstrates enhancing pelvic nodularity consistent with
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metastatic disease.
Fig. 21 Flowchart for evaluation of a non-ovarian cystic lesion with MRI characteristics and
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clinical features
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Fig. 22 Flowchart for evaluation of a non-ovarian solid lesion with MRI characteristics and
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clinical features
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Table 1. Differential Diagnosis of Non-Ovarian Adnexal Lesions SOLID
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CYSTIC
Uterine Leiomyoma
Ectopic Pregnancy
Fibrotic endometriosis
Paraovarian Cyst
Fallopian Tube Carcinoma
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Tuboovarian Abscess
Hydro- / Pyo- / Hematosalpinx
Retrorectal masses
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Peritoneal Inclusion Cyst
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Pelvic Congestion Syndrome / Pelvic
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Varices
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Tarlov Cyst
Mucocele of Appendix
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Bladder Diverticulum Pelvic Hematoma Lymphocele Endometriosis
Congenital uterine anomalies Pelvic Metastases
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S0899-7071(15)00211-9 doi: 10.1016/j.clinimag.2015.07.031 JCT 7891
To appear in:
Journal of Clinical Imaging
Received date: Revised date: Accepted date:
19 February 2014 17 July 2015 30 July 2015
Please cite this article as: Thawait Shrey K, Batra Kiran, Torigian Drew A., Chhabra Avneesh, Zaheer Atif, Johnson Stephen I., Magnetic Resonance Imaging Evaluation of Non Ovarian Adnexal Lesions, Journal of Clinical Imaging (2015), doi: 10.1016/j.clinimag.2015.07.031
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title of the submission: Magnetic Resonance Imaging Evaluation of Non Ovarian Adnexal Lesions Abbreviated Title: MRI of Non Ovarian Adnexal Lesions Authors: Shrey K Thawait1,MD; Kiran Batra2, MD; Drew A. Torigian3, MD MA; Avneesh Chhabra2, MD; Atif Zaheer2, MD; Stephen I. Johnson2, MD 1 Department of Radiology, Yale University - Bridgeport Hospital, 267 Grant Street Bridgeport, CT 06610 2 Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD 21287 3 Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia PA 19104 Emails of authors: Shrey K Thawait: [email protected] Kiran Batra: [email protected] Drew A. Torigian: [email protected] Avneesh Chhabra: [email protected] Atif Zaheer: [email protected] Stephen Johnson [email protected]
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Corresponding author: Stephen Johnson, MD Department of Radiology Johns Hopkins Hospital 601 North Caroline Street Baltimore, Maryland 21287 Office: (504) 473-2866 Fax: (410) 955-9446 Email: [email protected] Conflict of interest: NONE. The authors declare that they have no conflict of interest. Abstract Differentiation of non-ovarian from ovarian lesions is a diagnostic challenge. MRI of the pelvis provides excellent tissue characterization and high contrast resolution, allowing for detailed evaluation of adnexal lesions. Salient MRI characteristics of predominantly cystic lesions and predominantly solid adnexal lesions are presented along with epidemiology and clinical presentation. Due to its excellent soft tissue resolution, MR may be able to characterize indeterminate adnexal masses and aid the radiologist to arrive at the correct diagnosis, thus positively affect patient management. Keywords: adnexal lesion; magnetic resonance imaging (MRI); para-ovarian cyst, peritoneal inclusion cyst; leiomyoma; fallopian tube carcinoma
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Introduction A wide array of pathologies may present as a non-ovarian adnexal lesion. Accurate
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differentiation of such lesions from ovarian lesions and accurate lesion characterization are
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important, as correct diagnosis is crucial to avoid treatment delay or unnecessary therapy (1). These lesions are usually first encountered with ultrasound however, frequently pelvic ultrasonography lacks the specificity and will not be covered in this review (2). MRI offers
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excellent tissue characterization due to high soft tissue contrast and can aid in the diagnosis of such pathologies when incompletely evaluated with pelvic ultrasonography (2). MRI also offers
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high spatial resolution and multiplanar imaging capability, such that differentiation between nonovarian and ovarian lesions is feasible. The presence of a normal appearing ipsilateral ovary
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essentially excludes the presence of an ovarian lesion, whereas lack of visualization of a normal ovary may indicate an ovarian or non-ovarian lesion origin. MRI characterization of a nonovarian adnexal lesion is based on its morphological, signal intensity, and enhancement
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characteristics (1). The purpose of this pictorial review is to discuss the key MRI imaging
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features and clinical highlights of the most common cystic and solid non-ovarian adnexal lesions. Normal Anatomy
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The ovarian fossae, where the ovaries are generally seen in nulliparous women, are shallow peritoneal depressions occupying the lateral aspects of the rectouterine space bilaterally, located
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posterior to the broad ligaments and anterior to the ureters and internal iliac arteries (3). Ovarian position may be quite variable depending on urinary bladder distention, uterine size, rectosigmoid distention and presence of a pelvic lesion (3). MRI Technique MRI of the female pelvis may be performed on a 1.5 or 3 Tesla magnet. Three Tesla imaging provides increased signal to noise and CNR to improve image resolution and shorter image time (4). Drawbacks of using higher magnetic field strength include increased magnetic susceptibility, chemical shift, and RF inhomogeneity (4). The exact MRI protocol is guided by the clinical setting and by the available MRI scanner. Typically, axial T1-weighted images without and with fat suppression are obtained in order to differentiate macroscopic fat (which has high signal intensity on T1-weighted images without fat suppression and low signal intensity on fat-
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suppressed T1-weighted images) from proteinaceous fluid or subacute hemorrhage (which have high T1-weighted signal intensity without or with fat suppression). In addition, multiplanar T2weighted images are also obtained, often with fat suppression in the coronal plane to demonstrate
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lesional internal architecture including cystic and solid components (Table 1), and to delineate
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the anatomical relationship of the lesion with respect to the ipsilateral ovary and other pelvic organs. They are also useful for visualization of the internal architecture of the uterus and cervix.
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Diffusion-weighted images [with associated apparent diffusion coefficient (ADC) parametric map images] may also be obtained for improved detection and characterization of pelvic
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pathology (2). Qualitative assessment of signal intensities on diffusion-weighted images has shown significant differences in benign and malignant pathology, with high signal intensity was
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observed more frequently in malignant lesions (5). The combination of diffusion-weighted images with conventional MRI has been shown to improve the staging of ovarian cancer and peritoneal metastases. While ADC values for differentiating benign and malignant pathologies
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has widely varied among institutions for certain diseases such as cervical cancer, other entities such as peritoneal implants demonstrate restricted diffusion on DWI images with associated
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ADC values (5,6,7). Multiplanar fat-suppressed T1-weighted images after administration of Intravenous Gadolinium Based Contrast Agent (IV GBCA) are also obtained when possible in
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order to detect solid tissue components, peritoneal extension of disease, and vascular involvement. Please note, however, that IV GBCA is not administered to women who are
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pregnant or suspected to be pregnant. MRI was conducted for all patients by means of a 1.5-T or 3T system (Magnetom Symphony, Siemens, Erlangen, Germany) with the manufacturer's body and spine array coils. The entire liver was imaged in the transverse plane. First, we obtained axial T2 images through the entire pelvis (repetition time (TR)/echo time (TE): 5700/101; flip angle: 150°; slice thickness: 6 mm; matrix: 180 × 320) followed by T1 images without fat suppresion (repetition time (TR)/echo time (TE): 546/12; flip angle: 60°; slice thickness: 6 mm; matrix: 154 × 320) and T2 spacial coronal images (repetition time(TR)/echo time (TE): 1400/163; flip angle 60°; slice thickness: 12 mm; matrix: 154 × 320). DWI images (repetition time (TR)/echo time (TE): 3700/82; flip angle: 70°; slice thickness: 6 mm; matrix: 154 × 320). Sagittal VIBE (repetition time (TR)/echo time (TE): 10.2/4.85; flip angle: 70°; slice thickness: 4 mm; matrix: 154 × 320). Axial VIBE DWI images (repetition time (TR)/echo time (TE): 9.95/4.73; flip angle: 70°; slice thickness: 4
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mm; matrix: 154 × 320). Post contrast images (repetition time (TR)/echo time (TE): 9.95/4.73;
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flip angle: 70°; slice thickness: 4 mm; matrix: 154 × 320).
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Tubo-ovarian Abscess (TOA)
TOA typically presents as a complex lesion that involves the fallopian tube and/or ovary (8) and
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is the most common type of pelvic abscess in women of reproductive age (8) . In patients presenting with clinical symptoms of pelvic inflammatory disease, the presence of an adnexal
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lesion, age greater than 42 years and elevated erythrocyte sedimentation rate > 50 mm/hour (normal 0-10mm/hour) have been shown to be the best predictors of TOA (9). With widespread
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use of the broad-spectrum antibiotics, conservative treatment of TOA is usually successful (10). On MRI, TOA typically appears as a complex cystic lesion with internal septations, fluid-fluid or fluid-debris levels, and a thickened rim of 5 mm or thicker (11). A tubular fluid-filled structure
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due to pyosalpinx is also often seen. Low signal intensity foci of non-dependent gas may also be seen on T1-weighted and T2-weighted images, and the fluid contents has variable signal
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intensity depending on the presence and concentration of proteinaceous and cellular material, but is often hypointense on T1-weighted images and hyperintense on T2-weighted images (Fig 1)
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(10). Following administration of IV GBCA, enhancement of the septa and walls may be noted (10). Secondary findings include edema and inflammation of surrounding tissues with associated
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increased T2-weighted signal intensity and enhancement involving the mesenteric and omental fat, peritoneal thickening and enhancement, and pelvic organs.
Ectopic Pregnancy Implantation of the blastocyst at any site outside of the endometrium is termed ectopic pregnancy. Adhesions and scarring from prior inflammation lead to delayed tubal transit of embryo and prevent implantation in the endometrium. Several predisposing risk factors have been identified, such as previous ectopic pregnancy, previous tubal surgery, pelvic inflammatory disease, infertility, and smoking (12,13). The most common location for ectopic pregnancy is the fallopian tube (14). Levels of serum beta human chorionic gonadotropin are usually abnormally
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elevated (15). Although ultrasonography is the primary modality for the diagnosis of ectopic pregnancy, MRI can be helpful in equivocal cases, especially with presence of an interstitial or abdominal ectopic pregnancy. On MRI, a heterogeneous cystic lesion with a thickened wall and
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variably increased T1-weighted signal intensity components (due to subacute hemorrhage) and
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variably decreased T2-weighted signal intensity components (due to acute or subacute hemorrhage) may be seen (Fig 2). Additional findings such as hematosalpinx and
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hemoperitoneum may also be present (14,15).
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Para-ovarian Cyst
The para-ovarian (or paratubal) cyst arises within the broad ligament as a remnant of the Wolffian or Mullerian ducts usually adjacent to the ovary. This is most common in women in
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the 3rd-4th decades of life (16), accounts for 10-20% of adnexal lesions and may be bilateral or multiple (17). A paraovarian cyst does not show cyclical change whereas an ovarian cyst does.
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Most paraovarian cysts are benign. Predictors for malignancy include size over 5 cm, internal papillary excrescences and occurrence in reproductive-age women (18,19). On MRI, para-ovarian
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cysts are round or ovoid cystic lesions that are separate from the ipsilateral ovary (Fig 3), have thin walls with no or minimal enhancement, and contain simple fluid with low T1-weighted
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signal intensity and very high T2-weighted signal intensity relative to skeletal muscle (20). Hemorrhage within the cyst may lead to variably increased T1-weighted signal intensity and
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variably decreased T2-weighted signal intensity, and wall thickening or internal septations may also be present (Fig 3). Demonstration of enhancing soft tissue component after IV GBCA is worrisome for neoplasm. Para-ovarian cysts may also lead to ovarian torsion or rarely isolated tubal torsion (21) (Fig 4). Peritoneal Inclusion Cyst Localized peritoneal fluid contained by mesothelial lined adhesion is termed peritoneal inclusion cyst. It is commonly seen in premenopausal women with functioning ovaries and pelvic adhesions (22). Other predisposing factors include prior abdominal surgery, trauma, pelvic inflammatory disease, and endometriosis. On MRI, peritoneal inclusion cysts have low T1weighted signal intensity and very high T2-weighted signal intensity of simple fluid. Peritoneal inclusion cysts may be unilocular or septated, typically have thin minimally enhancing walls,
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have ill-defined borders defined by the peritoneal cavity, and abut and often surround one or both ovaries which appear normal (Fig 5). Occasionally, high signal intensity on T1-weighted images
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may be seen due to presence of proteinaceous fluid or hemorrhage (23).
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Hydrosalpinx / Hematosalpinx / Pyosalpinx
Depending on the cause of the obstruction, serous fluid, hemorrhage, or pus may accumulate
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within the fallopian tube resulting in distention, termed as hydrosalpinx, hematosalpinx, or pyosalpinx, respectively (24). Hydrosalpinx and pyosalpinx are commonly seen in women with
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pelvic inflammatory disease. Pyosalpinx is often bilateral and is associated with inflammatory changes such as edema, thickening, and enhancement of the tubal wall and surrounding pelvic
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tissues. Associated small bowel adynamic ileus or obstruction may also be seen. Hematosalpinx in the setting of endometriosis may be unilateral or bilateral. Other causes may include trauma, ectopic pregnancy, or malignancy (24). The distended fallopian tube usually assumes a tubular C-
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or S- shape, often with intraluminal mucosal folds similar to the spokes on a cogwheel, and is best visualized using multiplanar T2-weighted images (25). Simple fluid in a dilated fallopian
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tube shows low signal intensity on T1-weighted images and very high signal intensity T2weighted images (Fig 6). Hemorrhagic or proteinaceous fluid may have high signal intensity on
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T1-weighted images and variable signal intensity on T2-weighted images depending upon the age of hemorrhage (Fig 7). Fallopian tube carcinoma, although rare, should be suspected when
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nodular or solid enhancing components are present (24). Associated restriction of diffusion may also be seen on diffusion-weighted images. Other findings including lymphadenopathy or distant metastatic disease may also be encountered.
Pelvic Congestion Syndrome / Pelvic Varices Pelvic congestion syndrome is a common etiology of chronic pelvic pain, and is thought to have a multifactorial pathogenesis. Risk factors may include multiple prior pregnancies, a history of varicose veins, prior pelvic surgery, a retroverted uterus, and hormonal influences. Multiparous women of reproductive age are generally affected and complain of deep dull pelvic ache lasting > 6 months that is made worse by activities that increase intra-abdominal pressure (26). Pelvic congestion syndrome may be termed as primary, if no anatomic cause of venous obstruction is
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present. Secondary pelvic congestion syndrome may be caused by compression of the ovarian veins by a retroaortic left renal vein, the superior mesenteric artery (Nutcracker phenomenon), or as a component of iliofemoral deep venous thrombosis in May–Thurner syndrome (27). On
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MRI, pelvic varices appear as serpentine signal voids on non-contrast T1-weighted and T2-
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weighted images, although they may alternatively have increased signal intensity when there is slow blood flow. Pelvic varices demonstrate venous phase enhancement on T1-weighted images
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after contrast administration (Fig 8), and may be seen in the periuterine, periovarian, and/or perivaginal locations either unilaterally or bilaterally (28). Dilation of one or both ovarian veins
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to > 6 mm in diameter may also be seen in the setting of pelvic congestion syndrome. Furthermore, time resolved magnetic resonance venography may also be useful to depict
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retrograde flow in the dilated ovarian vein or veins filling the varices (29,30). However, it should be noted that presence of dilated gonadal veins and pelvic varices may be seen in asymptomatic women, particularly in those who have had prior pregnancy, and therefore the diagnosis of pelvic
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congestion syndrome can only be made definitively when a clinical history of chronic pelvic pain is also present.
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Tarlov Cyst / Perineural Sacral Cyst
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The estimated prevalence of Tarlov cysts is 5- 9% in the adult population (31). Dilated prominent nerve sleeves of spinal nerve roots produce these lesions (32). The most common location is at
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S2 and S3 levels. On MRI, Tarlov cysts follow the signal intensity characteristics of simple fluid with low signal on T1-weighted images and a very high signal on T2-weighted images (31). They are typically located in the sacral spinal canal and/or neural foramina, and can occasionally extend anteriorly into the pelvis, mimicking other pelvic or adnexal cystic lesions (Fig 9). Scalloping of the adjacent bone with an intact cortex, sacral canal widening, and neural foraminal enlargement may also be seen. However, no solid enhancing components are seen. Appendiceal Mucocele A mucocele of the appendix may uncommonly mimic an adnexal lesion and should be considered in patients with unexplained right lower quadrant abdominal pain (33,34). Abnormal mucus accumulation in the lumen of the appendix with luminal dilation leads to an appendiceal mucocele. The pathogenesis is related to obstruction of the proximal lumen or appendiceal
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orifice, and the most common etiologies include mucinous cystadenomas, mucosal hyperplasia, mucinous cystadenocarcinomas, and retention cysts (35). This entity is more commonly seen in middle aged women with a reported prevalence of 0.5-1% among patients undergoing
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appendectomy (36) and can mimic acute appendicitis. The other manifestations include
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asymptomatic palpable mass, intussusception, gastrointestinal bleeding, ureteral obstruction or hematuria, and abdominal distention from mucocele rupture, resulting in mucinous ascites
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(which is termed pseudomyxoma peritonei only when an appendiceal adenoma is the underlying lesion). On MRI, a well-defined tubular thin-walled cystic lesion, sometimes with invagination
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into the cecum, with rim enhancement is typically seen (37). The internal fluid typically has intermediate-high T1-weighted signal intensity and high T2-weighted signal intensity (Fig 10)
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(38). Focal enhancing nodules may also be seen, suggestive of mucinous cystadenoma or
cystadenocarcinoma. Associated pelvic lymphadenopathy or distant metastatic disease may be seen in the case of the latter (39). If there has been mucocele rupture, then complex loculated
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ascites is seen, typically with scalloping of adjacent parenchymal organs. Internal septations, peritoneal thickening and enhancement, enhancing nodules, and omental caking may also be
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Bladder Diverticulum
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seen.
An outpouching of bladder urothelium through the muscularis propria of the bladder wall
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constitutes a bladder diverticulum and may be congenital or acquired. Congenital diverticula are believed to form as a result of insufficient support of muscle at the ureterovesical junction (40). Boys are commonly affected and the presentation is at an age younger than 10 (40); hence, the congenital diverticulum is not usually confused with an adnexal lesion. An acquired diverticulum is more likely to mimic an adnexal lesion in women, although uncommon (41). When multiple diverticula are present, they are more commonly acquired. Bladder diverticula may also be seen in syndromes such as Ehlers-Danlos syndrome (42) and Menkes disease (43). On MRI, bladder diverticula have signal intensity similar to urine in the bladder on all pulse sequences, have thin walls, and communicate with the bladder lumen (Fig. 11). Calculi and enhancing malignant tumors may be present, with the former demonstrating low signal intensity on T1-weighted and T2-weighted images and no enhancement, and the latter demonstrating nodular enhancing components. Associated wall thickening may also be present.
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Uterine Leiomyoma Uterine leiomyoma is a benign, smooth muscle tumor which is the most common gynecologic
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tumor in the United States, and is clinically apparent in up to 25% of women (44). An exophytic
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or pedunculated uterine leiomyoma may simulate an adnexal mass. MRI establishes the myometrial origin of the lesion by demonstrating splaying of the uterine serosa or myometrium and absence of an intervening fat plane between the lesion and the uterus (45). On MRI,
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leiomyomas are typically sharply marginated with low- intermediate T1-weighted signal intensity and low T2-weighted signal intensity and demonstrate enhancement (46). However,
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presence of degeneration may lead to increased T1-weighted signal intensity, due to subacute hemorrhage or fatty change, or increased T2-weighted signal intensity without enhancement due
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to cystic/necrotic change (47,48). Vessels located between the uterus and the exophytic leiomyoma are typically seen as curvilinear or tortuous signal voids with venous phase enhancement (Fig 12). This finding, called the "bridging vessel sign", is present in up to 80% of
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cases and confirms a uterine origin of the lesion (49).
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Endometriosis
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Endometriosis has an estimated prevalence of 5–20% and affects women of reproductive age (50,51). The presence of functional endometrial glands and stroma outside the uterine cavity in
this disease may or may not be symptomatic. Chronic pelvic pain, dysmenorrhea and deep
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dyspareunia are the most common symptoms (52). The implant size may vary from microscopic endometriotic foci to large cysts (endometriomas). The sensitivity and specificity of MRI for the diagnosis of endometrioma are greater than 90% (53). On MRI, the signal characteristics may vary according to the age of hemorrhage, resulting in a mixed spectrum of appearances (54). However, characteristic MR imaging features of an endometrioma include an adnexal or ovarian lesion with high signal intensity on T1-weighted images and low signal intensity "shading" on T2-weighted images, without solid enhancing components (Fig 13) (55,56). Bilaterality and multiplicity of lesions also favor the diagnosis of endometriosis, and hydrosalpinges or hematosalpinges (Fig 7) may be present as well. The accuracy of MRI for detection of endometriomas is further increased by using fat-suppressed T1-weighted images (57). Fibrotic endometriosis appears as ill-defined low signal intensity lesions on T1-weighted and T2weighted images that enhance and occasionally contain high T1-weighted signal intensity
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hemorrhagic foci. They are seen in the pelvic peritoneal space, and can involve the cul-de-sac, uterosacral ligaments, broad ligaments, uterine wall, cervical wall, vaginal fornices, ureters, urinary bladder wall, bowel wall, body wall, and abdominal peritoneal cavity. Bowel obstruction
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or hydroureter may be visualized when there is bowel or ureteral obstruction, respectively. Fallopian Tube Carcinoma
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Fallopian tube carcinoma is rare, constituting 0.3 – 1% of all gynecological cancers (58). Presentation is nonspecific with vaginal bleeding being the most common presentation (59).
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Imaging findings pertain to the presence of a mass within the fallopian tube (Fig 14). On MRI, an adnexal cystic structure with low signal intensity on T1-weighted images and very high signal
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intensity on T2-weighted images, representing the dilated fallopian tube, is typically seen in association with wall thickening, enhancing mural nodules, or a solid enhancing mass that has slightly high T2-weighted signal intensity relative to skeletal muscle (60). Associated pelvic
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lymphadenopathy or distant metastatic disease may also be seen.
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Pelvic Hematoma
Pelvic hematoma may be seen in various clinical scenarios, and is common after surgery or
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trauma (61). On MRI, acute components of hemorrhage typically have low signal intensity on T1-weighted and T2-weighted images, whereas subacute components of hemorrhage have high
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signal intensity onT1-weighted images and variable signal intensity on T2-weighted images. Chronic components of hemorrhage will have very low signal intensity on T1-weighted and T2weighted images due to hemosiderin deposition (Fig 15). The "concentric ring sign" may also be seen, which is comprised of an inner peripheral rim of high T1-weighted signal intensity subacute hemorrhage and an outer peripheral rim of very low signal intensity chronic hemorrhage. Fluid-fluid levels and septations may also be present. However, no solid enhancing components are seen unless an underlying neoplasm is also present. If active hemorrhage is present, a focus or jet of extraluminal high signal intensity contrast material may be seen on postcontrast T1-weighted images. On serial imaging, hematomas will generally decrease in size and frequently resolve. Retrorectal developmental cyst
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The retrorectal space is a potential space between the posterior wall of the rectum anteriorly and the sacrum posteriorly (62). Tumors occurring in this space are extremely rare (63). Congenital lesions account for about half of all tumors and epidermoid, dermoid, developmental cysts (Fig
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16), and teratomas are the commonest (61). A dermoid cyst is more likely if MRI confirms the
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presence of fat content on fat-saturated images (Fig 17). MRI features such as smooth wellcircumscribed margins without any invasion may be seen with benign tumors while a
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heterogeneous solid tumor with an irregular / invasive margins, is more like to be malignant (64).
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Congenital uterine anomalies
The association between unicornuate uterus and renal anomalies such as agenesis has been well
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described (65,66). Abnormal or failed development of one of the paired müllerian ducts results in unicornuate uterus (67). A rudimentary horn may be present, which could be noncavitary, cavitary and non-communicating (Fig 18), or cavitary and communicating. Ultrasonography can
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be challenging in these cases due to atypical morphology of the uterus, and especially if echogenic endometrium within the rudimentary horn is absent (68). MRI is the best imaging
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technique to identify the rudimentary horn variant and to evaluate for the presence of associated
Pelvic Lymphocele
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renal anomalies (67).
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Pelvic lymphocele is a loculated fluid collection without an epithelial lining that develops following injury to lymphatic structures, most commonly from prior surgery or trauma. A lymphocele may develop in a significant proportion of post-operative cases of pelvic lymphadenectomy (69), and may cause symptoms due to secondary infection or mass effect upon adjacent structures (70). On MRI, lymphoceles typically appear as thin-walled cystic lesions with low T1-weighted and very high T2-weighted signal intensity similar to simple fluid without solid enhancing components (Fig 19). Subjacent susceptibility artifact on in-phase T1-weighted images due to surgical clips is frequently visualized, and internal septations may sometimes also be seen. However, solid enhancing components are not visualized. Pelvic Metastasis
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The most common primary tumors that spread to the pelvis are lymphoma and carcinomas of the breast, colon, and lung (71). On MRI, pelvic metastases generally demonstrate low-intermediate signal intensity on T1-weighted images and slightly high signal intensity on T2-weighted images
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relative to skeletal muscle, have restricted diffusion on diffusion-weighted images, and enhance
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(Fig 20). Presence of subacute hemorrhage may lead to increased T1-weighted signal intensity components, and presence of cystic/necrotic change leads to increased T2-weighted signal
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intensity components that do not enhancement (72). Associated pelvic lymphadenopathy or distant metastatic disease may also be seen.
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Conclusion
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MRI is useful in the detection and characterization of the non-ovarian adnexal lesions. After identification of a lesion as separate from the ovary and review of relevant clinical and laboratory based information about the patient, the next step is to assess its imaging features. The
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margins, shape, internal architecture, signal intensity characteristics, enhancement characteristics, and presence or absence of change in size and appearance since prior imaging all
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provide important clues on MRI to the most likely diagnosis (Fig 21, 22). While MRI does have limitations of cost and availability, MRI is useful to detect and characterize the indeterminate
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non-ovarian adnexal lesions and aid in guiding appropriate patient management.
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Figure Legends:
Fig. 1 Pyosalpinges (bilateral) and left tubo-ovarian abscess (TOA). 47 year-old-woman with
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abdominal pain, nausea and vomiting. (a) Axial T2-weighted and (b) Coronal post- IV GBCA
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T1-weighted images show dilated fluid filled tubular structures with decreased T2-weighted signal intensity (*) in adnexa representing bilateral pyosalpinges. Tubo-ovarian abscess is seen
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as a septated adnexal cystic lesion (arrows) adjacent to the left fallopian tube Fig. 2 Interstitial (cornual) ectopic pregnancy. 35 year-old-woman with previous history of
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ectopic pregnancies presents with amenorrhea, 1st trimester bleeding and severe pelvic pain. (a)
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Axial T1-weighted and (b) Axial T2-weighted images show thick-walled complex cystic lesion
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(arrows) in right adnexa in uterine cornu / interstitial portion of fallopian tube without intrauterine gestational sac seen in endometrial canal, compatible with cornual ectopic pregnancy. The right ovary is seen separately (*) Fig. 3 Para-ovarian cyst. 28 year-old-woman with infertility. (a) Axial T2-weighted and (b) Coronal T2-weighted image with fat suppression show small unilocular cyst (thick arrows) with very high signal intensity within the left adnexa. The left ovary (long arrows) is seen separately. Note arcuate configuration of uterus on axial image (curved arrow) Fig. 4 Isolated tubal torsion. 28 year-old-woman presented with right lower quadrant pain. Urine and serum pregnancy tests were negative. (a) Axial T2-weighted image shows a 4 cm right
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para-ovarian unilocular cyst with very high signal intensity (arrow). Note the normal right ovary anterior to the cyst with a dominant follicle (asterisk) (b) Coronal T2-weighted image shows a
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swirling appearance of the right fallopian tube (arrow). Surgical exploration revealed a normal
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right ovary with a 4-cm-size right fallopian tube and paratubal cyst complex which had torsed on itself three times. During surgery the right fallopian tube torsion was reduced after which viable
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adnexa was confirmed. Paraovarian cystectomy was then performed
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Fig. 5 Peritoneal inclusion cyst . 40 year-old-woman with pelvic pain 7 years after
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hysterectomy. (a) Axial T2-weighted image reveals a thin-walled unilocular cystic lesion (*) in right adnexa that partially surrounds the right ovary (arrow) and conforms to the shape of the
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peritoneal cavity. (b) Axial post IV GBCA T1-weighted image does not show any solid enhancing component. Right ovary (arrow) is again seen
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Fig. 6 Hydrosalpinx. 66 year-old-woman with history of breast carcinoma. (a) Axial T1-
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weighted, (b) Axial T2-weighted and (c) Sagittal T2-weighted images reveal a dilated fluid-filled
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tubular cystic structure (arrows) in right adnexa Fig. 7 Hematosalpinges (bilateral). 35 year-old-woman with history of chronic pelvic pain and endometriosis. (a) Axial T1-weighted and (b) Axial T2-weighted images show dilated tubular structures (*) in adnexae. Note the increased T1-weighted and decreased T2-weighted signal intensity on the left, consistent with hemorrhagic fluid. On the right side an area of increased T1 signal intensity is noted (arrow), consistent with subacute hemorrhage Fig. 8 Pelvic congestion syndrome. 48 year-old-woman with chronic pelvic and vaginal pain. (a) Coronal post IV GBCA Maximum Intensity Projection (MIP) T1-weighted image and (b)
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Axial post IV GBCA T1-weighted images show dilated enhancing left ovarian vein and periuterine varices (arrows)
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Fig. 9 Tarlov cysts. 46 year-old-woman with history of irregular menses. (a) Axial T1-weighted and (b) Coronal T2-weighted image with fat suppression shows a dilated tubular cystic lesion
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(short arrows) in a right sacral foramen entering the pelvis in a right adnexal location. Note
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expansion of the right sacral foramen (*) and the separate right ovary (long arrow in a) Fig. 10 Appendiceal mucocele. 71 year-old-woman with right lower quadrant abdominal pain.
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(a), and (b) Sequential Axial T2-weighted images demonstrate dilated blind-ending tubular cystic lesion (arrows) originating from cecal base (white circle) (c) Axial post IV GBCA T1-
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weighted image with fat suppression shows minimal peripheral rim enhancement.
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Fig. 11 Bladder Diverticulum. 66 year old male with urinary retention. (a) Axial T2 images of the pelvis and (b) coronal T2 images of the pelvis demonstrate a small outpouching of the
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bladder, continuous with the bladder lumen, with a thin wall.
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Fig. 12 Pedunculated uterine leiomyoma. 43 year-old-woman with history of pelvic mass. (a) Axial T1-weighted image and (b) Axial post IV GBCA T1-weighted image with fat suppression show a large pedunculated low-intermediate signal intensity right adnexal mass (*) arising from the uterus (U). This is confirmed by the “bridging vessel sign” which is seen as serpentine flow voids in (a) between mass and uterus which demonstrate enhancement in (b) (long arrow). The right ovary was seen separately (not shown) Fig. 13 Endometriosis. 37 year-old-woman with history of pelvic inflammatory disease. (a) Axial T1-weighted image and,(b) Axial T2-weighted images show a dilated fluid-filled thickwalled tubular structure (*) in right adnexa, consistent with hydrosalpinx and chronic salpingitis.
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Several cystic structures are also seen (thick short arrows) in left adnexa with high T1-weighted signal intensity and low T2-weighted signal intensity, consistent with endometriomas. The right
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ovary is seen separately (long thin arrow) Fig. 14 Fallopian tube carcinoma. 60 year-old-woman with pelvic mass on prior
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ultrasonography. (a) Axial and (b) Sagittal T2-weighted images show heterogeneous solid adnexal mass (M), centered within a dilated tubular fluid-filled left fallopian tube (arrow) and
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extending posterior to uterus (U)
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Fig. 15 Pelvic Hematoma. 46-year-old-woman who underwent hysterectomy for leiomyosarcoma 8 months ago now presents with pelvic pain. (a) Axial T1-weighted image with
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fat suppression shows several rounded lesions in the pelvis with inner peripheral rim of high signal intensity (thick white arrow) and outer peripheral rim of very low signal intensity (thin
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white arrow), consistent with the "concentric rim sign" which is characteristic of subacute
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hematoma. (b) Axial T2-weighted image shows lesions with central high signal intensity (thick
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white arrows) and peripheral very low signal intensity (thin white arrow). (c) Axial contrastenhanced T1-weighted image with fat suppression shows lack of enhancement of the lesions Fig. 16 Congenital retrorectal developmental cyst. 38 year-old-woman presents with intermittent deep pelvic pain for several months. (a) Axial T2-weighted image and (b) Axial T2-weighted image with fat saturation show a well circumscribed mass in the retrorectal area (arrows). Note the smooth margins. The cystic portions appear T2 hyperintense (curved arrow). (c) Axial T1weighted image with fat saturation shows the cystic portions within this mass to be T1 hypointense (curved arrow). (d) Axial T1-weighted image after IV GBCA with fat saturation shows enhancement (arrow). Note that the cystic components do not enhance (curved arrow).
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The rectum has been displaced laterally (labeled as R) and the uterus is seen anteriorly (labeled as U). Biopsy showed fragments of benign fibromuscular tissue focally lined by simple columnar
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and metaplastic squamous epithelium, consistent with a retrorectal developmental cyst. Note the
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absence of fat signal within the lesion, which would have favored a dermoid cyst
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Fig. 17 Dermoid cyst. 36 year-old-woman presents with pelvic pain. (a) Axial T1-weighted without fat saturation show a well defined mass adjacent to the rectum (arrows). Note the smooth
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margins. A large portion appears T1 hyperintense (curved arrow). (b) Axial T1-weighted image
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with fat saturation shows the fat component to be hypointense (curved arrow). The presence of fat makes dermoid cyst as the most likely diagnosis. Note the relationship of this dermoid cyst
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with the rectum (labeled as R) and the uterus (labeled as U) Fig. 18 Unicornuate uterus with a non-communicating rudimentary uterine horn. 34 year-old-
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woman presents with pelvic pain. (a) Axial T2-weighted image shows rudimentary horn on the
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left side (thin arrow) that does not communicate with the uterine cavity (thick arrow). Note
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central low signal intensity within rudimentary horn (curved arrow) along with normal myometrial tissue layers. The inner myometrium is seen with low signal intensity (black arrowhead), outer myometrium with high signal intensity (chevron). (b) Axial T1-weighted image with fat suppression shows central high signal intensity (curved arrow) in keeping with subacute hemorrhage within rudimentary horn endometrial canal Fig 19 Lymphocele. 75 year old female status post lymph node dissection secondary to prostate cancer. Coronal T2 images demonstrate with a left adnexal fluid collection demonstrating hyper T2 signal with a small amount of layering debris.
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Fig 20 Pelvic metastasis. 63 year old female with metastatic endometrial carcinoma. (a) Axial T2 fat saturation image demonstrates multiple cystic pelvic collections, the more anterior
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collection demonstrates nodularity. (b) Axial T1 fat saturated image after the administration of
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intravenous gadolinium contrast demonstrates enhancing pelvic nodularity consistent with
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metastatic disease.
Fig. 21 Flowchart for evaluation of a non-ovarian cystic lesion with MRI characteristics and
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clinical features
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Fig. 22 Flowchart for evaluation of a non-ovarian solid lesion with MRI characteristics and
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clinical features
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Table 1. Differential Diagnosis of Non-Ovarian Adnexal Lesions SOLID
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CYSTIC
Uterine Leiomyoma
Ectopic Pregnancy
Fibrotic endometriosis
Paraovarian Cyst
Fallopian Tube Carcinoma
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Tuboovarian Abscess
Hydro- / Pyo- / Hematosalpinx
Retrorectal masses
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Peritoneal Inclusion Cyst
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Pelvic Congestion Syndrome / Pelvic
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Varices
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Tarlov Cyst
Mucocele of Appendix
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Bladder Diverticulum Pelvic Hematoma Lymphocele Endometriosis
Congenital uterine anomalies Pelvic Metastases
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