Adnexal Masses and Problem Solving Pelvic MRI

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Piers Payne
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1 28th Congress of the Hungarian Society of Radiologists RCR Session Budapest June 2016 Adnexal Masses and Problem Solving Pelvic MRI DrSarah Swift St James s University Hospital Leeds, UK

2 Objectives Characterisation of adnexal masses with MRI When Why How

3 Adnexal masses Increased use of imaging to assess patients electively and emergently CT as the primary investigation KUB, CTU, CTC Increased detection of adnexal masses

4 Adnexal masses Multidisciplinary meetings frequently ask Where is it? What is it? Does it need to come out? If so how?

5 Differential diagnosis of adnexal masses 2 clinical scenarios Adnexal mass in the symptomatic patient Will be resected Question is how big or small operation? Incidental finding of an adnexal mass Aim of further imaging is to characterise benign lesions which can be managed conservatively

6 US and MR for adnexal masses Determine which patients may benefit from MRI Clinical and biochemical features crucial Sohaibet al, ClinRad 2005

7 False positive diagnoses of malignancy by US Complex cystic lesions endometrioticor haemorrhagic cysts and dermoids Solid masses - leiomyomataand fibromata

identified on MRI MRI performed better than US in

8 MRI correct diagnosis of benign lesion Haemorrhage, clot, fat and non-perfused debris can be readily identified on MRI MRI performed better than US in cases where CA 125 was normal or only slightly elevated

9 Ultrasound Looks benign Suspicious US Looks malignant Premenopausal, normal tumour markers, low clinical index of suspicion Premenopausal, normal markers intermediate or low clinical suspicion High clinical suspicion for malignancy Elevated CA 125 MRI has little to add MRI for characterisation CT for staging

10 Ultrasound Looks benign Suspicious US Looks malignant Premenopausal, normal tumour markers, low clinical index of suspicion Premenopausal, normal markers intermediate or low clinical suspicion High clinical suspicion for malignancy Elevated CA 125 MRI has little to add MRI for characterisation CT for staging

11 Ultrasound Looks benign Suspicious US Looks malignant Premenopausal, normal tumour markers, low clinical index of suspicion Premenopausal, normal markers intermediate or low clinical suspicion High clinical suspicion for malignancy Elevated CA 125 MRI has little to add MRI for characterisation CT for staging

12 Ultrasound Looks benign Suspicious US Looks malignant Premenopausal, normal tumour markers, low clinical index of suspicion Premenopausal, normal markers intermediate or low clinical suspicion High clinical suspicion for malignancy Elevated CA 125 MRI has little to add MRI for characterisation CT for staging Can also apply this to CT findings

13 Problem solving MRI T1W T2W Fat Saturation Contrast Enhancement Diffusion Weighted Imaging Simple fluid Fat Blood Non-perfused debris Perfused solid material

14 Mature Fat T2W T1W T1W+Fat Sat Dermoid

15 Big lesions may be difficult to fully assess with Ultrasound

16 Dermoids be careful Malignant change Squamous carcinoma Skin elements, wall of the lesion Poor prognosis

17 2 years later

18 Blood T2W T1W T1W + Fat Sat Variable appearance depending on age

19 Blood of differing ages Shading of contents on T2W MRI Characteristic of endometrioma

20 HaemorrhagicEndometriosis Shading of contents on T2W = Endometrioma Haemorrhagiclesion with incomplete septations plical folds = Haematosalpinx

21 Fibrotic Endometriosis Tethering of adjacent structures

22 Endometriosis be careful Solid looking mass on CT

23 MRI shading on T2W, blood on T1W, solid enhancing focus, cystic ademomyosis Endometrioidcarcinoma arising in an endometrioma

24 Solid elements? Give contrast Non enhancing solid foci Benign fibrous lesion T1W Solid enhancing focus Likely malignant T2W T1W +Gad

25 Solid elements? Give contrast Non enhancing solid foci Benign fibrous lesion T2W Solid enhancing focus Likely malignant T1W + Gad

26 Patterns of solid enhancement Serous borderline ovarian tumours Cystic and surface papillary types Younger age group Better prognosis Fertility sparing surgery Important diagnosis

27 Patterns of solid enhancement Serous borderline ovarian tumours Cystic and surface papillary types Younger age group Better prognosis Fertility sparing surgery Important diagnosis

28 Solid Adnexal Masses Is it uterine or adnexal? What is the signal intensity on T2W? Does it enhance?

29 Three key signs Acute angle Claw Feeding vessels Obtuse angle U Courtesy of Dr John Spencer

30 Solid Adnexal Masses Is it uterine or adnexal? What is the T2 SI? Does it enhance?

31 Solid Adnexal Masses Is it uterine or adnexal? What is the T2 SI? Does it enhance?

32 Solid Adnexal Masses Is it uterine or adnexal? What is the T2 SI? Does it enhance?

33 Solid Adnexal Masses Is it uterine or adnexal? What is the T2 SI? T2W b = 800 Does it enhance? T1W T1 + Gad

34 Solid Adnexal Masses Low T2 signal and lack of enhancement suggest fibroid lineage Adenofibromacan look heterogeneous on T2 and show variable enhancement Low b = 800 value on DWI gives confidence to call a lesion benign Associated with free fluid in Meigs Syndrome T2W b = 800 T1W T1 + Gad

35 Solid Adnexal Masses be careful Change in bowel habit Palpable mass CT bilateral solid adnexal masses

36 Solid Adnexal Masses be careful Change in bowel habit Palpable mass CT bilateral solid adnexal masses

37 Solid Adnexal Masses be careful Change in bowel habit Palpable mass CT bilateral solid adnexal masses Sigmoid Carcinoma Ovarian metastases

38 Ovarian metastases Krukenberg tumours Original description of bilateral solid masses Not always the case Variable appearance Indistinguishable from primary ovarian tumour Important differential diagnosis

39 Adnexal Masses in the Acute Setting Symptomatic adnexal masses will be resected How? Cancer surgery Simple excision of the mass Role of further imaging Try to characterise the mass Allow decision making about patient management

40 Acute pain, known adnexal lesion

41 Acute pain, known adnexal lesion T1W T2W T1W+ Fat Sat Torsion

42 Intermittent pain, pelvic mass

43 Torsion of adnexal masses In adults there is usually an underlying benign lesion Commonly dermoid Symptoms can be intermittent and non-specific Intramural haemorrhage is a recognised finding on MRI

44 Abdominal pain, fever

45 Abdominal pain, fever

46 Associated with longstanding IUD Spreads by contiguity Crosses tissue planes Mimics malignancy Actinomycosis

47 Actinomycosis 6 months later Important diagnosis Conservative management Removal of IUD Antibiotic therapy

48 Adnexal Masses and Problem MRI excellent problem solving tool particularly where the prior probability of malignancy is low Solving MRI Be careful to look for neoplastic change

49 Adnexal Masses and Problem Metastatic disease to the ovaries is not always solid Solving MRI Pain may reflect a complication of benign pathology or an inflammatory process

50 Thank you

52 Solid Adnexal Masses Is it uterine or adnexal? What is the T2 SI? Does it enhance?

53 Solid Adnexal Masses Is it uterine or adnexal? What is the T2 SI? Does it enhance?

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