MR imaging diagnosis of dilated fallopian tubes

Size: px

Start display at page:

Download "MR imaging diagnosis of dilated fallopian tubes"

Julian Woods
6 years ago
Views:

1 MR imaging diagnosis of dilated fallopian tubes Poster No.: C-314 Congress: ECR 2009 Type: Educational Exhibit Topic: Genitourinary Authors: P. Papadopoulou, N. Michailidis, I. Kalaitzoglou, A. Haritanti, P. Psychidis-Papakyritsis, D. Goulis, D. Rousso, A. S. Dimitriadis; Thessaloniki/GR Keywords: endometriosis, hydrosalpinx, fallopian tubes, pelvic inflammatory disease DOI: /ecr2009/C-314 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 41

2 Learning objectives To illustrate and discuss the MR imaging features and differential diagnosis of dilated fallopian tubes. Background Dilated fallopian tubes are a common finding in female pelvis imaging, most often associated with pelvic inflammatory disease or endometriosis, conditions that obliterate the fimbriated end of thefallopian tube. It may also result from peritubal adhesions, be a part of a complex adnexal mass, or the result of distal obtruction, in the uterus or even the vagina. Although endovaginal ultrasoundis the primary diagnostic tool, MR imaging is an invaluable complementary method, especially in complex lesions which may simulate malignancy. Imaging findings OR Procedure details 1. Imaging findings a. Morphology Visualization of the normal fallopian tubes is not possible for conventional MRI. Commonest configuration of dilated fallopian tubes is that of a fluid filled, tubular structure, folded to form a C or S Page 2 of 41

3 Fig.: The right tube contains fluid and has a C configuration. shape. A tortuous or serpentine appearance may also be observed. A comma shape tube is characteristic of torsion. An additional, highly specific finding is the presence of mural folds or plicae. Page 3 of 41

4 Fig.: The right fallopian tube is distended, C shaped and there is a plica (arrow). Plicae are thought to represent effacement of the mucosa and submucosa by the dilated tube, or blunting of the mucosal folds by chronic salpingitis. These plicae may be absent or flattened in case of significant hydrosalpinx secondary to salpingitis. In order to demonstrate the shape of the tubes and the presence or plicae, imaging in multiple planes or 3D imaging is usually required. The walls of a dilated tube may be thin or thick, depending on the underlying pathology. Page 4 of 41

5 Fig.: Left hydrosalpinx with low signal intensity on T1 W images, intermediate signal intensity on T2 W images and thick, double-layer walls. The dilated tubes may measure a few millimeters to several centimeters in diameter and when large they may simulate ovarian pathology. b. Signal Intensity The contents of the dilated tube have variable signal intensity, depending on the viscosity, protein concentration and presence of acute or chronic hemorrhage. Hydrosalpinx has typically low signal intensity on T1 W images and high signal intensity on T2 W images. Page 5 of 41

6 Fig.: The left salpinx is dilated, C shaped, with low signal intensity on T1 W images and high on high T2 W images. High signal intensity on T1 W images is significantly correlated to endometriosis. Shortening of the signal intensity on T2 W images, a finding widely known as shading and typical of endometriomas or chocolate cysts is usually not present in tubal endometriosis and in any case it is not significantly correlated. Furthermore, T2 W shortening may be noted in the presence of other pathologies causing hemorrhage, as well as in pelvic inflammatory disease. Page 6 of 41

7 Fig.: This cystic lesion, with a plica consistent with a dilated tube, has high signal intensity on T1 W images, intermediate-high signal intensity on T2 W images and high signal intensity on T2 W fat sat images. Layering on T2 W images is compatible with the presence of pus or hemorrhage. Increased signal intensity on T1 W or T2 W images is better identified in fat suppressed images. c. Contrast enhancement The wall of the dilated salpinx tends to enhance with contrast. Page 7 of 41

8 Fig.: Dilated fallopian tubes bilaterally. Both tubes contain fluid and have a C configuration. There is subtle enhancement of the wall of the dilated tubes. In case of inflammation the enhancement is thicker and more vivid. Application of contrast material helps identify solid portions in complex lesions and to differentiate solid tissue from blood clots. Contrast enhancement is better delineated in fat suppressed T1 W images. d. Multiplicity The two most common pathologies that cause dilatation of the salpinx, pelvic inflammatory disease and endometriosis, tend to affect the adnexa bilaterally, therefore the finding of bilateral dilated fallopian tubes is very common. e. Identification of ipsilateral ovary. When the ipsilateral ovary appears normal on imaging we can safely exclude the possibility of ovarian origin of the lesion in question. Page 8 of 41

9 Fig.: Bilateral hydrosalpinx (white arrows). The ovaries are easily identified and have a normal appearance (red arrows). Some free fluid is also present. f. Differential diagnosis Fluid filled bowel loops may some times simulate dilated fallopian tubes. Imaging in multiple planes helps eliminate this issue. Furthermore, bowel loops present peristalsisrelated artifacts around themselves and change appearance in subsequent sequences. Page 9 of 41

10 Fig.: There fluid-filled distended bowel loops to the right side of the uterus which is enlarged due to the presence of multiple fibromas. Note the peristalsis-related artifacts and the change of morphology in different planes. When the dilated fallopian tubes have complex appearance and solid portions they must be differentiated from other complex adnexal masses, especially malignant ones and may need further investigation with explorative laparoscopy or laparotomy. Page 10 of 41

11 Fig.: There are complex cystic lesions in both adnexa which in surgery were proved to be serous cystadenocarcinomas. 2. Clinical examples a. Pelvic inflammatory disease. This is a common, sexually transmitted condition in women of reproductive age. It is an ascending infection and the commonest causative organisms are Chlamydia trachomatis and Neisseria gonorrheae. Delayed treatment may lead to tubo-ovarian abscesses and pyosalpinx or hydrosaplinx due to the formation of adhesions. Long term sequela include infertility, ectopic pregnancy and chronic pelvic pain. Hydrosalpinx is characterized by thin walls, minimal enhancement and absence of other findings of inflammation. Page 11 of 41

12 Fig.: The right fallopian tube is dilated, especially the fimbriated end, tortuous, with very high signal intensity contents in T2 W images. The lesion has some mass effect on the bladder. In case of pyosalpinx, the dilated tube usually shows significant tortuousity with thick walls and intense enhancement with contrast. Page 12 of 41

13 Fig.: Both fallopian tubes are dilated and tortuous with thick enhancing walls. Clinical and laboratory findings were consistent with inflammation. Thick walls with a double-layer configuration correlate with acute and chronic salpingitis. The presence of gas bubbles in the dilated salpinx is a rare, highly specific finding. The adjacent structures including the uterus are also involved in the inflammatory reaction and the ovary may be enlarged and polycystic-like. The pelvic fat may show stranding and free fluid may be present in the cul-de-sac. b. Endometriosis Endometriosis, a common disease in women of reproductive age, is the presence of endometrial glands and stroma outside the uterus. It causes the formation of adhesions resulting in 28% of women with endometriosis to have tubal abnormalities in hysterosalpingography. The typical MR imaging appearance of endometriosis affecting the tubes includes bilateral hematosalpinx with high signal intensity on T1 W images with high or heterogeneously low signal intensity on T2 W images. Page 13 of 41

14 Fig.: Bilateral hematosalpinx with contents of high signal intensity in T1 W and T1 W fat sat images. There is some shading, a finding that is not typical for tubal endometriosis c. Ectopic pregnancy Ninety-five percent of all ectopic pregnancies occur within the fallopian tubes. The finding of empty endometrial cavity in the presence of increased b-human chorionic gonadotropin is diagnostic of ectopic pregnancy. When the ectopic pregnancy can be identified in a tube the findings include hematosalpinx, and a heterogeneous adnexal mass composed of hematoma and gestational sac. Hematoma has a characteristic appearance that depends on the age of the blood. The gestational sac, with or without fetoplacental tissue, has low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. Page 14 of 41

15 Fig.: The left fallopian tube is distended by the gestational sac and hemorrhagic products. There is a rim of very low signal intensity in T2 W images consistent with presence of hemosiderine. There is minimal contrast enhancement. Ascites is often present and in case of rupture of the gestational sac, it may be hemorrhagic. d. Benign and malignant ovarian neoplasms. Benign and malignant ovarian masses may involve the ipsilateral salpinx. In these cases the dilated tube may be a part of a more complex structure with other cystic or solid elements. Page 15 of 41

16 Fig.: Right ovarian fibothecoma with mild distention of the ipsilateral salpinx. Ascites is also present. Page 16 of 41

17 Fig.: There is a borderline serous cystadenocarcinoma with enhancing solid components, arising from the right ovary. The ipsilateral tube was found distended in surgery. e. Previous surgery Surgery in the female pelvis can result in adhesions or accidental tubal ligation with resultant dilatation of the tubes. Page 17 of 41

18 Fig.: The contents of this tubular lesion have elevated signal intensity in T1 W images, a finding compatible with hemorrhage or high protein concentration. f. Cervical or vaginal obstruction Cervical cancer may in advanced stages result in occlusion of the cervical os and formation of hematometra and subsequent hematosalpingx. Page 18 of 41

19 Fig.: Cervical cancer obliterates the cervical os and causes hematometra and hematosalpinx. In the context of Mullerian anomalies on page the vagina may be obstructed (imperforated hymen), with hematocolpos, hematometra and hematosalpinx. Page 19 of 41

20 Fig.: The uterus is didelphis and there is obstruction of the vagina due to imperforated hymen, with hematocolpos, left hematometra and left hematosalpinx. Page 20 of 41

21 Images linked within the text of this section: Fig. Additional images for this section: Page 21 of 41

22 Fig. 1: Bilateral hematosalpinx with contents of high signal intensity in T1 W and T1 W fat sat images. There is some shading, a finding that is not typical for tubal endometriosis Page 22 of 41

23 Fig. 2: Both fallopian tubes are dilated and tortuous with thick enhancing walls. Clinical and laboratory findings were consistent with inflammation. Page 23 of 41

24 Fig. 3: The left fallopian tube is distended by the gestational sac and hemorrhagic products. There is a rim of very low signal intensity in T2 W images consistent with presence of hemosiderine. There is minimal contrast enhancement. Page 24 of 41

25 Fig. 4: The right tube contains fluid and has a C configuration. Page 25 of 41

26 Fig. 5: The right fallopian tube is distended, C shaped and there is a plica (arrow). Page 26 of 41

27 Fig. 6: Left hydrosalpinx with low signal intensity on T1 W images, intermediate signal intensity on T2 W images and thick, double-layer walls. Page 27 of 41

28 Fig. 7: The left salpinx is dilated, C shaped, with low signal intensity on T1 W images and high on high T2 W images. Page 28 of 41

29 Fig. 8: This cystic lesion, with a plica consistent with a dilated tube, has high signal intensity on T1 W images, intermediate-high signal intensity on T2 W images and high signal intensity on T2 W fat sat images. Page 29 of 41

30 Fig. 9: Dilated fallopian tubes bilaterally. Both tubes contain fluid and have a C configuration. There is subtle enhancement of the wall of the dilated tubes. Page 30 of 41

31 Fig. 10: Bilateral hydrosalpinx (white arrows). The ovaries are easily identified and have a normal appearance (red arrows). Some free fluid is also present. Page 31 of 41

32 Fig. 11: There fluid-filled distended bowel loops to the right side of the uterus which is enlarged due to the presence of multiple fibromas. Note the peristalsis-related artifacts and the change of morphology in different planes. Page 32 of 41

33 Fig. 12: There are complex cystic lesions in both adnexa which in surgery were proved to be serous cystadenocarcinomas. Page 33 of 41

34 Fig. 13: The right fallopian tube is dilated, especially the fimbriated end, tortuous, with very high signal intensity contents in T2 W images. The lesion has some mass effect on the bladder. Page 34 of 41

35 Fig. 14: Right ovarian fibothecoma with mild distention of the ipsilateral salpinx. Ascites is also present. Page 35 of 41

36 Fig. 15: There is a borderline serous cystadenocarcinoma with enhancing solid components, arising from the right ovary. The ipsilateral tube was found distended in surgery. Page 36 of 41

37 Fig. 16: The contents of this tubular lesion have elevated signal intensity in T1 W images, a finding compatible with hemorrhage or high protein concentration. Page 37 of 41

38 Fig. 17: Cervical cancer obliterates the cervical os and causes hematometra and hematosalpinx. Page 38 of 41

39 Fig. 18: The uterus is didelphis and there is obstruction of the vagina due to imperforated hymen, with hematocolpos, left hematometra and left hematosalpinx. Page 39 of 41

40 Conclusion Dilated fallopian tubes can be correctly identified in MR imaging, on the basis of morphology. The signal intensity of the contents may be used to further characterize the lesion and the underlyingpathology, most commonly pelvic inflammatory disease or endometriosis. Large masses that have irregular, thick walls must undergo laparoscopy and be evaluated to exclude the possibility ofmalignancy. Personal Information Peggy Papadopoulou Asklipios Magnitiki Tomografia Thessaloniki References 1. Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST. CT and MR Imaging of Ovarian Tumors with Emphasis on Differential Diagnosis. RadioGraphics 2002; 22: Tukeva TA, Aronen HJ, Karjalainen PT, Molander P, Paavonen T, Paavonen J. MR Imaging in Pelvic Inflammatory Disease: Comparison with Laparoscopy and US. Radiology 1999;210: Nagayama M, Watanabe Y, Okumura A, Amoh Y, Nakashita S, Dodo Y. Fast MR Imaging in Obstetrics. Radiographics. 2002;22: Dohke M, Watanabe Y, Okumura A, Amoh Y, Hayashi T, Yoshizako T, Yasui M, Nakashita S, Nakanishi J, Dodo Y. Comprehensive MR Imaging of Acute Gynecologic Diseases. RadioGraphics 2000; 20: Outwater EK, Siegelman ES, Chiowanich P, Kilger AM, Dunton CJ, Talerman A. Dilated fallopian tubes: MR imaging characteristics. Radiology 1998; 208: Mitchell DG, Outwater EK. Benign gynecologic disease: applications of magnetic resonance imaging. Top Magn Reson Imaging 1995; 7: Outwater EK, Dunton CJ. Imaging of the ovary and adnexa: clinical issues and applications of MR imaging. Radiology 1995; 194:1-18 Page 40 of 41

41 8. McCormack WM. Pelvic inflammatory disease. N Engl J Med 1994; 330: Bis KG, Vrachliotis TG, Agrawal R, Shetty AN, Maximovich A, Hricak H. Pelvic endometriosis: MR imaging spectrum with laparoscopic correlation and diagnostic pitfalls. RadioGraphics 1997; 17: Jeong YY, Outwater EK, Kang HK. Imaging Evaluation of Ovarian Masses. RadioGraphics 2000; 20: Kim SH, Kim SH, Yang DM, Kim KA. Unusual Causes of Tubo-ovarian Abscess: CT and MR Imaging Findings. RadioGraphics 2004;24: Sala EJ, Atri M, Magnetic resonance imaging of benign adnexal disease.top Magn Reson Imaging Aug;14(4): Page 41 of 41

2D and 3D MR imaging in the assessment of Fallopian tube features

2D and 3D MR imaging in the assessment of Fallopian tube features Poster No.: C-1292 Congress: ECR 2010 Type: Topic: Scientific Exhibit Genitourinary Authors: J. Takahama, S. Kitano, N. Marugami, A. Takahashi,