D URING the past i8 months at this institution, infusion urography has been

Size: px

Start display at page:

Download "D URING the past i8 months at this institution, infusion urography has been"

Peter Wheeler
6 years ago
Views:

MILWAUKEE, WISCONSIN Infusion excretory urography not only clearly delineates the urinary tract structures, but provides additional information about the type of pelvic mass present.

1 SEPTEMBER, 1975 ABSTRACT: EVALUATION OF PELVIC MASSES DURING INFUSION EXCRETORY UROGRAPHY* By THOMAS J. IMRAY, M.D. MILWAUKEE, WISCONSIN Infusion excretory urography not only clearly delineates the urinary tract structures, but provides additional information about the type of pelvic mass present. Benign uterine fibroids show contrast enhancement in a significant number of cases, whereas endometrial and cervical malignancies give no specific pattern. Cystic and mixed ovarian neoplasms show rim opacification in over 50 per cent of cases, and the presence of this rim sign points strongly to an ovarian lesion. The opacification of solid ovarian tumors cannot be differentiated from that of uterine fibroids unless other identifying features such as specific calcification or visualization of a normal uterus are present. Pelvic inflammatory disease shows no specific type of opacification. Excretory urography is part of the preoperative evaluation in most patients with pelvic mass lesions. By utilizing the infusion method, high quality excretory urograms are obtained, and, in addition, helpful information is obtained regarding the type of pelvic mass present. D URING the past i8 months at this institution, infusion urography has been performed routinely in all nonhypertensive adult excretory urograms. Definite opacification of both normal pelvic structures and pelvic masses was noted, prompting the review of all available infusion urograms in females with surgically and pathologically documented pelvic masses. Uterine fibroids gave a rather typical solid to mottled opacification. Cystic ovarian tumors showed an opacified rim following infusion of contrast medium, whereas solid ovarian lesions often showed a mottled opacification. MATERIAL AND METHOD For the past i8 months at this institution, infusion excretory urography has been the routine mode of adult urinary tract examinaton. All infusion urograms are monitored and individualized according to the problems encountered, although a miniltum routine filming sequence is followed in all patients. Following preliminary roen tgenograms of the abdomen, a dose of 300 cc. of commercially prepared 30 per cent Methylglucamine diatrizoate is infused via a 19 gauge needle. A film localized to the kidneys is obtained at minutes, and a roentgenogram of the entire abdomen is obtained at io minutes after the beginning of infusion (usually the time required to complete the infusion). From that point on, we tailor all studies, obtaining oblique, upright, coned and tomographic films as indicated. A final prone roentgenogram is routine at the completion of the examination. Records and roentgenograms of 126 patients with proved pelvic masses were reviewed. Of these patients, 8o had sufficient preoperative information available to qualify for this study. Patients suspected of renovascular hypertension were not included in this study. All infusion urograms were reviewed regarding: (i) the roentgenographic presence or absence of a pelvic mass; (2) the presence of contrast enhancement; and (,) the type of opacification noted. * From the Department of Radiology, The Medical College of Wisconsin, Milwaukee, Wisconsin. 6o

VOL. 125, No. i Pelvic Masses During Infusion Urography 6i TABLE I No. Rim Solid or Mottled No Opacification Uterine Tumors A.Leiomyomata 47 0 40 (8 per cent) 7 B. Endometrial Neoplasm 6 o i C.

Solid 6 0 3 (o per cent) 3 Pelvic Inflammatory Disease 6 I I 4 RESULTS The 8o cases reviewed were divided into 3 major categories: uterine tumors; ovarian tumors; and pelvic inflammatory disease.

2 VOL. 125, No. i Pelvic Masses During Infusion Urography 6i TABLE I No. Rim Solid or Mottled No Opacification Uterine Tumors A.Leiomyomata (8 per cent) 7 B. Endometrial Neoplasm 6 o i C. Carcinoma of Cervix Ovarian Tumors A. Cystic io (o per cent) 0 #{231} B. Mixed (cystic and solid) 4 3 ( per cent) i i C. Solid (o per cent) 3 Pelvic Inflammatory Disease 6 I I 4 RESULTS The 8o cases reviewed were divided into 3 major categories: uterine tumors; ovarian tumors; and pelvic inflammatory disease. The presence of contrast enhancement and the type of opacification obtained were tabulated for each group (Table i). Forty-seven cases with uterine leiomyomata were studied. None showed rim opacification. Forty showed definite contrast enhancement, with either a solid or mottled appearance (Fig. I, A and B). Seven cases with uterine fibroids showed no opacification. In these fibroids were quite small, and no soft tissue mass except an apparently normal uterus could be identified. Two others had large, densely calcified uterine fibroids, and no opacification could be detected, possibly because of the presence of calcium. A total of 10 of the 7 cases had uterine fibroids containing calcifications, which varied from focal punctate calcifications to dense calcification of the entire fibroid. Even in the presence of calcification, contrast enhancement could be detected in 8 cases. Frequently, margins of the uterine fibroids were better delineated allowing determination of actual size. Uterine malignancies showed opacification in only i of the 6 cases reviewed. This patient had a large endometrial carcinoma which had caused moderate enlargement of the uterus. The tumor extended through the uterine wall to involve several adjacent loops of small bowel with fistula formation. The mass showed mottled opacification and was roentgenographically identical to the contrast enhancement seen in many cases of uterine leiomyomata. FIG. i. (A) Preliminary roentgenogram showing a pelvic soft tissue mass in a 33 year old female. (B) Ten minutes after infusion there is homogeneous opacification of the pelvic mass. An intrauterine contraceptive device is present. Pathologic diagnosis was multiple uterine leiomyomata.

3 6 Thomas J. Imray SEPTEMBER, Fic. z. (A) Preliminary roentgenogram showing a soft tissue mass clearly separate from the bladder in a 21 year old female. (B) Twenty minutes after infusion there is definite opacification of the cyst wall (arrows). Pathologic diagnosis was mucinous cystadenoma, right ovary. Of the cases of carcinoma of the cervix reviewed, i showed opacification of a roentgenographically normal uterus. No abnormal opacification could be detected. Ovarian tumors are divided into 3 groups according to their gross pathologic characteristics: (I) cystic, (2) solid, and (,) mixed (i.e., those tumors having both cystic and solid elements). A total of 20 ovarian masses was studied, io of which were cystic. Fifty per cent of these cystic ovarian tumors showed definite contrast enhancement of the cyst wall during infusion urography (Fig. 2, A and B). In i of these lesions, a multilocular cystic malignant teratoma, the septa were enhanced by contrast in addition to the cyst wall (Fig. 3, A and B). Another cystic ovarian tumor occurred in association with a myomatous uterus. The preliminary film revealed a single large pelvic mass, eccentric in configuration, but homogeneous in density. However, the infusion urogram showed definite contrast enhancement of the myomatous mass which could be clearly separated from the cystic ovarian tumor. One of the cystic tumors that did not show contrast enhancement was a dermoid cyst. This tumor contained no calcium, but the radiolucent characteristic of the cyst contents could be appreciated on the preliminary study. The cyst wall appeared radiopaque, lying between the fatty cyst fluid and the fat covering other adjacent pelvic structures. The cyst wall was clearly visible both before and after infusion. Since no definite change could be detected, this case was rated as no enhancement. Of the remaining 4 cases of cystic ovarian tumors that did not show opacification of the cyst wall, one which was later revealed to be a small ( cm. in its greatest diameter) serous cystadenoma showed no mass on any study. In the other 3, the cystic ovarian tumors could be identified, but no cyst wall opacification could be detected. Six solid ovarian tumors were encountered; none showed rim opacification. Three lesions showed solid or mottled contrast enhancement (Fig., A and B). The opacification could not in itself be differentiated from that seen in uterine fibroids. The 3 remaining solid ovarian tumors showed no contrast enhancement. A soft tissue mass could, however, be identified on the infusion urograms in all 3 cases. Four ovarian tumors were placed in the mixed category, i.e., those containing both solid and cystic elements. Three of these lesions showed contrast enhancement of the cyst walls, and I lesion showed mottled

VOL. 125, No. i Pelvic Masses During Infusion Urography 63 I - FIG. 3. (A) Preliminary roentgenogram shows a poorly defined pelvic and abdominal mass in a i6 year old female.

Pathologic diagnosis was malignant teratoma of the ovary with multiple cystic areas.

This lesion was a Brenner cell tumor of the ovary with both cystic and solid elements. There were 2 dermoid cysts in this group, both having typical calcifications present.

4 VOL. 125, No. i Pelvic Masses During Infusion Urography 63 I - FIG. 3. (A) Preliminary roentgenogram shows a poorly defined pelvic and abdominal mass in a i6 year old female. (B) Twenty minutes after infusion, opacification of the wall of the abdominal mass (solid arrows) and opacification of septa within the mass (open arrow) are shown. Pathologic diagnosis was malignant teratoma of the ovary with multiple cystic areas. opacification of the solid portions of the tumor in addition to revealing contrast enhancement of the cyst wall. This lesion was a Brenner cell tumor of the ovary with both cystic and solid elements. There were 2 dermoid cysts in this group, both having typical calcifications present. In one instance, the cyst wall showed contrast enhancement. Neither showed any opacification of the solid elements. The remain- FIG. 4. (A) Preliminary roentgenogram of an i8 year old female with amenorrhea and masculinizing signs and symptoms for i 8 months. (B) Twenty minutes after infusion there is homogeneous opacification of the pelvic soft tissue mass. Pathologic diagnosis was arrhenoblastoma, left ovary.

64 Thomas J. Imray SEPTEMBER, 1975 ing case was a patient with bilateral granulosa cell ovarian tumors which showed a small area of cyst wall opacification in the right ovarian mass.

Four of these patients showed no evidence of contrast enhancement. One patient showed definite rim opacification due to a 6 cm.

One other case showed mottled enhancement of a pelvic soft tissue mass, similar in appearance to a myomatous uterus, except that the borders of the mass were very indistinct.

5 64 Thomas J. Imray SEPTEMBER, 1975 ing case was a patient with bilateral granulosa cell ovarian tumors which showed a small area of cyst wall opacification in the right ovarian mass. There was also opacification of a normal sized uterus, clearly separating it from the bilateral adnexal masses. Pelvic inflammatory disease was the primary etiology in 6 cases of pelvic masses. Four of these patients showed no evidence of contrast enhancement. One patient showed definite rim opacification due to a 6 cm. serous cyst of the left fallopian tube associated with chronic salpingitis. One other case showed mottled enhancement of a pelvic soft tissue mass, similar in appearance to a myomatous uterus, except that the borders of the mass were very indistinct. The patient had no uterine leiomyomata, only chronic salpingitis with multiple tubo-ovarian adhesions. DISCUSSION Total body opacification and its value in the evaluation of abdominal masses was first described by O Connor and Neuhauser in I963. The authors noted that following high doses of intravenous contrast media, opacification of liver and bowel wall as well as abnormal abdominal masses occurred Cystic intraabdominal masses could be identified. In addition, opacification of the cyst wall following intravenous injection of contrast medium was noted in this and other reports.2-47 #{176} The contrast enhancement of the cyst wall seen in pelvic neoplasms is the result of the opacification of the blood vascular pool. The opacification of the cyst wall is due to the circulating contrast medium in the capillary bed of the cyst wall which can be visualized as a rim around the nonopacified cyst fluid. Because i to 2 cm. of cyst wall are tangential to the roentgen beam, this rim can be visualized, thus giving a I to 2 cm. effective tissue thickness. In almost all cases, the best opacification of the cyst wall occurred on roentgenograms taken at the time of completion of the infusion, the time of maximum plasma contrast medium levels. The opacification of the cyst wall continues about 30 minutes after completion ofinfusion, with diminishing intensity. The persistence of this opacification corresponds to the sustained plasma contrast medium levels obtained by the infusion method of excretory urography.3 It is highly unlikely that there is any active or passive accumulation of contrast in the cyst wall. The walls of ovarian cysts are in general not hypervascular, and therefore the opacification is not due to increased circulation of the cyst wall, which is the explanation offered for the visualization of the gallbladder wall during infusion cholecystography. The cyst wall was best visualized in the dermoid cysts of the ovary. But since the cyst wall could often be seen prior to the administration of contrast medium, it was quite difficult to evaluate contrast enhancement. In the dermoid cysts studied, only 2 showed definite contrast enhancement of the cyst wall. However, the cyst wall was visible in all cases prior to and following infusion. This ease of visualization of the teratoma wall is due to the radiolucent fat within the cyst and the surrounding fat in the pelvis. Opacification of solid and mixed ovarian lesions is also best explained by the sustained high plasma contrast medium levels. This explanation is supported by the fact that the best opacification occurs at the completion of infusion. The type of opacification was quite similar to that seen in uterine fibroids. These 2 lesions could be differentiated only if: (i) a normal uterus could be distinguished from the ovarian tumor; (2) typical psammomatous calcifications of ovarian carcinoma were present; or (3) typical calcifications of uterine fibroids or an ovarian dermoid were present. Uterine opacification was seen often during this study. Frequently the normal uterus could be differentiated from the ovarian mass because of the homogeneous uterine opacification. Such opacification of a normal uterus is probably a consequence of the rich capillary bed of the uterus.

VOL. 125, No. I Pelvic Masses During Infusion Urography 6 The high incidence of contrast enhancement found in this study is in keeping with observations in other studies.

Although Birnholz theory may be valid, this opacification is more likely to be due to the opacification of the intravascular and interstitial spaces of the uterine fibroids.

Large and small bowel were frequently superimposed on the pelvic mass. Also feces in the rectosigmoid was projected over most pelvic masses, giving a mottled appearance.

6 VOL. 125, No. I Pelvic Masses During Infusion Urography 6 The high incidence of contrast enhancement found in this study is in keeping with observations in other studies. #{176} Birnholz postulated that contrast enhancement was due to passive interstitial accumulation of the contrast agent, thus giving the hysterogram effect. Although Birnholz theory may be valid, this opacification is more likely to be due to the opacification of the intravascular and interstitial spaces of the uterine fibroids. An attempt to differentiate solid from mottled opacifications was abandoned because making a clear distinction between these 2 patterns was often not possible. Large and small bowel were frequently superimposed on the pelvic mass. Also feces in the rectosigmoid was projected over most pelvic masses, giving a mottled appearance. The time of maximum opacification, as mentioned previously, was usually at completion of infusion; however, problems existed in evaluating this finding. First, all excretory urograms are tailored, so that comparable films were not obtained in all cases. Second, because of the amount of contrast agent used, a brisk diuresis occurs. The bladder becomes moderately distended during the course of the study, altering the position of pelvic masses. As the bladder distends, the mass is elevated over the sacrum, thus increasing the apparent radiodensity of the mass. Third, any change in technical factors will alter the apparent radiodensity of all soft tissue masses. Fourth, ureteral compression devices decrease the anteroposterior diameter of the lower abdomen, therefore enhancing the visualization of pelvic masses by displacing overlying bowel. Fifth, prone films also alter relationship of the bladder to the pelvic mass, and the bladder will often partially or completely obscure the mass. Tomography, which has been used for the visualization of the gallbladder wall, has proved useful in the evaluation of pelvic masses. Although additional information can be obtained by this method, we do not routinely use pelvic tomography because of the additional time and pelvic irradiation encountered. Department of Radiology The Medical College of Wisconsin 8700 W. Wisconsin Avenue Milwaukee, Wisconsin REFERENCES I. BIRNHOLZ, J. C. Uterine opacification during excretory urography: definition of previously unreported sign. Radiology, I972, 505, CARLSON, D. H., and GRISCOM, N. T. Ovarian cysts in newborn. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., I972, ii#{243}, CATTELL, W. R. Excretory pathways for contrast media. Invest. Radiol., I970, 5, GRISCOM, N. T., and NEUHAUSER, E. B. D. Total body opacification. 7. Pediat. Surg., 1966, 5, KITTREDGE, R. D., KANICK, V., and FINBY, N. Value of nephrotomography in differential diagnosis of abdominal masses. AM. J. ROENT- GENOL., RAD. THERAPY & NUCLEAR MED., 1966, 98, LOVE, L., MONCADA, R., MELAMED, M., and COOPER, R. Infusion tomography of the female pelvis. Scientific Exhibit at the 9th Scientific Assembly and Annual Meeting of the Radiological Society of North America, Chicago, 111., Nov , MARTIN, D. J., GRI5COM, N. T., and NEU- HAUSER, E. B. D. Further look at total body opacification effect. Brit. 7. Radiol., 1972, 45, MITTY, H. A., and SCHAPIRA, H. E. Total body opacification in adult. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1972, 115, O CONNOR, J. F., and NEUHAUSER, E. B. D. Total body opacification in conventional high dose intravenous urography in infancy. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1963, 90, PHILLIPS, J. C., EASTERLY, J. F., and LANGSTON, J. W. Contrast enhancement of pelvo-abdominal masses: rim sign. Radiology, 1974, 112, II. RABUSHKA, S. E., LOVE, L., and MONCADA, R. Infusion tomography of gallbladder. Scientific Exhibit at the 8th Scientific Assembly and Annual Meeting of the Radiological Society of North America, Chicago, Ill., Nov. 26-Dec. I, SALZMAN, E., and MCCLINTOcK, J. Opacification of small bowel with intravenously administered contrast medium. Exhibit, I enth International Congress of Radiology, Montreal, Canada, Aug., 1962.

A Practical Approach to Adnexal Masses

A Practical Approach to Adnexal Masses Darcy J. Wolfman, MD Section Chief of Genitourinary Imaging American Institute for Radiologic Pathology Clinical Associate Johns Hopkins Community Radiology Division