Fallopian tube carcinoma: pearls and pitfalls

Transcription

1 Fallopian tube carcinoma: pearls and pitfalls Poster No.: C-0543 Congress: ECR 2013 Type: Educational Exhibit Authors: C. N. Tentugal, T. M. Cunha, A. Félix ; Portimão/PT, Lisbon/PT Keywords: Cancer, elearning, Ultrasound, MR, CT, Genital / Reproductive system female, Pathology DOI: /ecr2013/C 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 54

2 Learning objectives To illustrate the radiologic spectrum of fallopian tube carcinoma. To present the key imaging signs that allow the distinction between fallopian tube diseases from other complex adnexal masses. Page 2 of 54

3 Background Primary fallopian tube carcinoma is a rare gynecologic malignancy that typically affects postmenopausal women. Most patients with this pathology undergo imagiological workup for symptoms that include abdominal or pelvic pain and vaginal bleeding. Page 3 of 54

4 Imaging findings OR Procedure details ANATOMY The fallopian tubes are uterine appendages located bilaterally at the superior portion of the uterine cavity. Each tube extends laterally from the medial end of the upper lateral margin of the uterus to the ipsilateral ovary. During the adult reproductive years, the fallopian tubes are approximately 9-11 cm long and 1-4 mm wide in luminal diameter. They are composed of four segments (from the medial aspect to the lateral aspect): Intramural portion (uterine and interstitial) Isthmus Ampulla Infundibulum Fig. 1: Drawing demonstrating the fallopian tube segments. References: C. N. Tentugal - Department of Radiology, CHBA, Portimão, Portugal At the ovarian end of the fallopian tube, the infundibulum communicates with the peritoneal cavity, forming a connection between the endometrial and peritoneal cavities. Page 4 of 54

5 Throughout its extrauterine course, the fallopian tube lies in a peritoneal fold along the superior margin of the broad ligament, the mesosalpinx. Arterial supply Branches of the uterine artery Branches of the ovarian artery These branches are small and located within the mesosalpinx. Fig. 2: Drawing of the fallopian tube anatomy (ligaments and blood supply). References: C. N. Tentugal - Department of Radiology, CHBA, Portimão, Portugal Normal fallopian tubes are not usually seen on ultrasound, CT or MR images unless they are outlined by pelvic fluid Fig. 3 on page 29. Lymphatic drainage Page 5 of 54

6 Para-aortic nodes Common iliac nodes Internal iliac nodes External iliac nodes Inguinal nodes Fig. 4: Axial contrast enhanced CT images demonstrating the lymphatic drainage of the fallopian tubes. References: C. N. Tentugal - Department of Radiology, CHBA, Portimão, Portugal IMAGING OF THE FALLOPIAN TUBE The small calibre and variable course of the normal fallopian tubes make these structures difficult to visualize on cross-sectional imaging. Paradoxically, when sufficiently distended to be readily visible on imaging, it often becomes a challenge to differentiate them from other pelvic fluid collections or adnexal masses. Page 6 of 54

7 Ultrasound (US) is usually the first modality of choice in the evaluation of patients with gynecologic symptoms and pelvic masses. Distended and enlarged tubes can be usually identified using transabdominal or transvaginal ultrasound (TVUS). Some specific imaging features are described in fallopian tube pathology, namely: tubular shape Fig. 5: Bilateral hidrosalpinx. Axial T1-weighted MR image demonstrating the characteristic tubular shape of dilated fallopian tubes (arrow heads). References: F. Torrinha - Department of Radiology, IPOLFG, Lisbon, Portugal folded configuration (distinguished from bowel by lack of peristaltic activity) Page 7 of 54

8 Fig. 6: (A) Transvaginal ultrasound and (B) Sagittal T2-weighted MR image of a dilated fallopian tube showing the typical appearance of a tubular and folded structure. References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal typically well-defined wall linear echoes protruding into the tube lumen (plicae) Page 8 of 54

9 Fig. 7: Sagittal T2-weighted MR image of a tubular structure demonstrating a "waist" sign (arrowhead) and plicae (arrows), in keeping with hidrosalpinx. References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal "waist" sign (indentations along opposite sides of a cystic mass) Fig. 7 on page 33 and Fig. 8 Page 9 of 54

10 Fig. 8: Axial contrast enhanced CT image of a left hidrosalpinx with a slight "waist" sign (arrows). References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal "beak" sign Page 10 of 54

11 Fig. 9: Pelvic inflammatory disease with bilateral salpingitis in a 22-yearold woman. Axial T1 fat saturated MR image after gadolinium demonstrates bilateral salpingitis with the right fallopian tube showing the "beak" sign (arrow). References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal These signs are seen both in US and MRI studies and help determining if an adnexal mass has its origin in the fallopian tube, which can be very challenging sometimes. Causes of fallopian tube pathology: Pelvic inflammatory disease (PID) Page 11 of 54

12 Fig. 10: Pelvic inflammatory disease in a 47-year-old patient who presented with pelvic pain, fever and leucocitosis. Axial contrast enhanced CT images demonstrate a left tubular structure with a thick and enhancing wall in keeping with salpingitis (arrow). Note the IUD (arrowhead) and fluid in the pouch of Douglas (*). References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Endometriosis Ovulation induction Tubal ligation, post-hysterectomy or salpingo-oophorectomy Fallopian tube tumour (benign and malignant) PRIMARY FALLOPIAN TUBE CARCINOMA (PFTC) Page 12 of 54

13 PFTC is a very rare malignancy that accounts for only 0.3%-1.1% of all gynecologic cancers and typically affects postmenopausal women. The most common type of PFTC is the serous adenocarcinoma. PFTC is often insidious with nonspecific symptoms at presentation. Patients may complain of pain, vaginal bleeding or discharge, or an adnexal mass. The combination of the classic symptoms of PFTC is seen in less than 15% of patients and is called the Latzko triad: Intermitent serosanguineous vaginal discharge Colicky lower abdominal or pelvic pain relieved by the vaginal discharge Adnexal mass The pathognomonic clinical feature of this malignancy is called hydrops tubae profluens which refers to intermittent discharge of clear or blood-tinged fluid spontaneously or on pressure followed by shrinkage of the adnexal mass. However, this type of presentation is not common (approximately 5%). Fig. 11: 61-year-old female patient with a right tubo-ovarian carcinoma who presented with hydrops tubae profluens. (A) Transvaginal ultrasound demonstrates a complex tubular structure with fluid (*) and solid components (arrow). (B) Axial contrast enhanced CT demonstrates the same structure as in (A) with enhancement of the solid components. These features are highly suggestive of a fallopian tube malignancy. References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Most PFTC arise in the ampulla. Page 13 of 54

14 Although PFTC imaging is sometimes nonspecific, the most common finding is a relatively small solid unilateral adnexal mass that is often associated with a dilated fallopian tube, appearing as a large mixed mass with cystic and solid components. MRI is therefore often required for further characterization. On MRI, the solid component of the PFTC usually demonstrates low signal intensity on T1-weighted images (T1WI) and high signal intensity on T2-weighted images (T2WI). The wall and solid components of fallopian tube cancers may show enhancement on T1weighted images. Fig. 12: 64-year-old patient with an ultrasound indeterminate adnexal lesion with previous left oophorectomy due to endometriosis. (A) and (B) axial, and (C) coronal T2WI; (D) axial T1WI; (E) and (F) axial T1 fat saturated MR images after gadolinium. These images demonstrate a dilated left fallopian tube (*) with a solid component which is hypointense on T2WI and slightly hyperintense on T1WI (arrow). This solid component enhances after gadolinium injection (arrow in E and F). These features are characteristic of a fallopian tube carcinoma (serous carcinoma). References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal At pathologic examination, the tumour appears predominantly solid, with small spots of cystic necrosis or hemorrhage. Page 14 of 54

15 Fig. 13: Fallopian tube carcinoma. 73-year-old patient with abnormal vaginal discharge. (A), (B) and (C) Transvaginal ultrasound shows a dilated fallopian tube with solid vegetations (*). (D) Coronal and (E) sagittal T2WI; (F)coronal T1WI; (G) coronal T1 fat saturated MR image after gadolinium. The solid vegetations are well appreciated in the T2WI (arrow) and enhance after contrast administration. On the T1WI the solid vegetations are difficult to observe. Note the characteristic "waist" sign of a dilated fallopian tube (arrow in F). References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Page 15 of 54

16 Fig. 14: Fallopian tube carcinoma. 73-year-old patient with abnormal vaginal discharge. A and B: Photograph of gross specimen of the uterus and the left adnexa of the previous patient demonstrating multiple vegetations in the left fallopian tube which correspond to the fallopian tube carcinoma. References: A. Félix - Department of Pathology, IPOLFG, Lisbon, Portugal Fig. 15: 63-year-old patient with abnormal vaginal bleeding. Transvaginal ultrasound demonstrated a normal endometrial cavity (not shown) and a right adnexal cystic Page 16 of 54

17 tubular structure (*) with apparent solid content within it (arrowhead). The ovaries were clearly identified. A MRI was advised to further characterize this fallopian tube content. References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Fig. 16: 63-year-old patient with abnormal vaginal bleeding (previous patient). A) Sagittal and (B) axial T2WI; (C) axial T1WI; (D) axial T1 fat saturated MR image after gadolinium. MRI shows a dilated right fallopian tube with hemorrhagic/hight protein content (*) (hyperintense in T1WI) and an enhancing solid mass (arrowhead) suggestive of a right fallopian tube carcinoma, which was confirmed after surgery (serous adenocarcinoma). References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Page 17 of 54

18 Fig. 17: 63-year-old patient with abnormal vaginal bleeding (previous patient). Gross specimen of the right fallopian tube: solid mass with luminal grow causing dilation of the remaining tube corresponding to a serous adenocarcinoma of the right fallopian tube previously described on ultrasound and MRI. References: A. Félix - Department of Pathology, IPOLFG, Lisbon, Portugal Mimics of fallopian tube carcinoma: Dilated fallopian tube from other cause Fig. 18: Bilateral hidrosalpinx due and cervical cancer. (A) and (B) axial T2WI showing a slight hyperintense cervical cancer (white arrow) which causes a bilateral hidrosalpinx. Note the "beak" sign (arrowhead) and small plicae in keeping with the dilated fallopian tubes. References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Peritoneal inclusion cyst Page 18 of 54

19 Fig. 19: Peritoneal pseudocyst in 45-year-old woman with left hemicolectomy for colon adenocarcinoma 6 years before. T2WI: Right-sided peritoneal inclusion cyst simulating hidrosalpinx. Note the normal ipsilateral ovary with follicles (arrow) and surrounding loculated fluid conforming to the shape of the peritoneal cavity. The left ovary is also seen. References: T. M. Cunha - Department of Radiology, IPOFLG, Lisbon, Portugal Mucocele of the appendix Page 19 of 54

20 Fig. 20: Mucocele of the appendix in a 66-year-old woman. (A) Axial contrast enhanced CT demonstrating a fluid attenuation tubular structure on the right(*). U - uterus. (B) Axial T1WI and (C) T2WI confirming the fluid filled tubular structure (*) which is similar to a dilated fallopian tube. This structure connected to the cecum making the diagnosis of a mucocele of the appendix very likely. References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Mucinous cystadenoma of the ovary Page 20 of 54

21 Fig. 21: Mucinous cystadenoma of the left ovary in a 51-year-old woman with previous histerectomy. Transvaginal ultrasound showing a cystic structure with thin septae inside it (arrow). This lesion was difficult to characterize by ultrasound and a MRI was suggested. References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Fig. 22: Mucinous cystadenoma of the left ovary in a 51-year-old woman with previous histerectomy (same patient as in fig. 22) (A) Sagittal T2WI (B) Axial T1WI (C) Axial T2WI. The lesion observed on ultrasound corresponded to a rounded structure (arrowhead) which contained thin septae inside. References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Paraovarian cyst Page 21 of 54

22 Fig. 23: Paraovarian cyst in a 22-year-old-woman. (A) Sagittal and (B) Axial T2WI; (C) Axial T1WI; (D) Axial T1 fat saturated MR image after gadolinium. A large cystic lesion is observed (*). The ovaries were individualized. This was a large paraovarian cyst. References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Lymphocele Page 22 of 54

23 Fig. 24: Bilateral pelvic lymphoceles after selective lymphadenectomy for ovarian cancer. Axial contrast enhanced CT demonstrates thin walled cystic lesions with fluis attenuation adjacent to the external iliac vessels, with surgical clips in their vicinity The right one being slightly tubular in shape. These are post-surgical lymphoceles. References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Lymphangioma Page 23 of 54

24 Fig. 25: Lymphangioma in a 66-year-old woman. A) Transvaginal ultrasound shows a left pelvic thin walled cystic lesion with reticular septations. (B) and (C) axial non-enhanced CT show the same lesion with fluid attenuation (*) adjacent to the left iliac external vessels (arrow). References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Other Page 24 of 54

25 Fig. 26: 66-year-old patient with endometrial carcinoma and hematometra. (A) Axial T1WI (B) axial and (C) sagittal T2WI show a distended endometrial cavity with blood (*) which simulates a fallopian tube carcinoma. Note the endometrial lesion (black arrow) and the compressed myometrium (white arrow). References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Fig. 27: Hydrometra due to obstruction of the external cervical os. (A) and (B) axial contrast enhanced CT of a patient who presented with pelvic pain. The endometrial Page 25 of 54

26 cavity is distended with low attenuation fluid (*), compressing the myometrium (arrow). This appearance is similar to a dilated fallopian tube. References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Fig. 28: Hematosalpinx caused by non evolutive ectopic pregnancy in a 27-year-old patient. (A) Transabdominal ultrasound showing a cystic lesion with internal echoes (*) (B) axial T2WI (C) axial T1WI (D) axial T1 fat saturated MR image after gadolinium. The hematosalpinx (*) is of intermediate-signal intensity with a high-signal intensity peripheral ring on T1WI and heterogeneous high-signal intensity on T2WI. There is a paraovarian gestational sac-like structure in the adnexa (arrow head) which supports the diagnosis of ectopic pregnancy. The left ovary is seen anteriorly to the fallopian tube (red arrow). (E) Gross specimen. References: T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal SUMMARY Key imaging signs suggestive of fallopian tube pathology: Tubular shape Folded configuration Plicae "Waist" sign "Beak"sign Page 26 of 54

27 Key imaging signs suggestive of primary fallopian tube carcinoma: Key imaging signs suggestive of fallopian tube pathology Mixed solid and cystic mass Solid component: usually low T1WI and high T2WI Enhancement of solid component + Page 27 of 54

28 Images for this section: Fig. 1: Drawing demonstrating the fallopian tube segments. C. N. Tentugal - Department of Radiology, CHBA, Portimão, Portugal Page 28 of 54

29 Fig. 2: Drawing of the fallopian tube anatomy (ligaments and blood supply). C. N. Tentugal - Department of Radiology, CHBA, Portimão, Portugal Page 29 of 54

30 Fig. 3: Coronal T2-weighted MR image showing a normal right fallopian tube surrounded by ascitis (arrow). L: Uterinus corpus with anterior subserosal leiomyoma; *:Left ovarian tumour (serous-papilliferous carcinoma). T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Page 30 of 54

31 Fig. 4: Axial contrast enhanced CT images demonstrating the lymphatic drainage of the fallopian tubes. C. N. Tentugal - Department of Radiology, CHBA, Portimão, Portugal Page 31 of 54

32 Fig. 5: Bilateral hidrosalpinx. Axial T1-weighted MR image demonstrating the characteristic tubular shape of dilated fallopian tubes (arrow heads). F. Torrinha - Department of Radiology, IPOLFG, Lisbon, Portugal Page 32 of 54

33 Fig. 6: (A) Transvaginal ultrasound and (B) Sagittal T2-weighted MR image of a dilated fallopian tube showing the typical appearance of a tubular and folded structure. T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Fig. 7: Sagittal T2-weighted MR image of a tubular structure demonstrating a "waist" sign (arrowhead) and plicae (arrows), in keeping with hidrosalpinx. T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Page 33 of 54

34 Fig. 8: Axial contrast enhanced CT image of a left hidrosalpinx with a slight "waist" sign (arrows). T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Page 34 of 54

35 Fig. 9: Pelvic inflammatory disease with bilateral salpingitis in a 22-year-old woman. Axial T1 fat saturated MR image after gadolinium demonstrates bilateral salpingitis with the right fallopian tube showing the "beak" sign (arrow). T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Page 35 of 54

36 Fig. 10: Pelvic inflammatory disease in a 47-year-old patient who presented with pelvic pain, fever and leucocitosis. Axial contrast enhanced CT images demonstrate a left tubular structure with a thick and enhancing wall in keeping with salpingitis (arrow). Note the IUD (arrowhead) and fluid in the pouch of Douglas (*). T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Page 36 of 54

37 Fig. 11: 61-year-old female patient with a right tubo-ovarian carcinoma who presented with hydrops tubae profluens. (A) Transvaginal ultrasound demonstrates a complex tubular structure with fluid (*) and solid components (arrow). (B) Axial contrast enhanced CT demonstrates the same structure as in (A) with enhancement of the solid components. These features are highly suggestive of a fallopian tube malignancy. T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Fig. 12: 64-year-old patient with an ultrasound indeterminate adnexal lesion with previous left oophorectomy due to endometriosis. (A) and (B) axial, and (C) coronal T2WI; (D) axial T1WI; (E) and (F) axial T1 fat saturated MR images after gadolinium. These images demonstrate a dilated left fallopian tube (*) with a solid component which is hypointense on T2WI and slightly hyperintense on T1WI (arrow). This solid component enhances after Page 37 of 54

38 gadolinium injection (arrow in E and F). These features are characteristic of a fallopian tube carcinoma (serous carcinoma). T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Fig. 13: Fallopian tube carcinoma. 73-year-old patient with abnormal vaginal discharge. (A), (B) and (C) Transvaginal ultrasound shows a dilated fallopian tube with solid vegetations (*). (D) Coronal and (E) sagittal T2WI; (F)coronal T1WI; (G) coronal T1 fat saturated MR image after gadolinium. The solid vegetations are well appreciated in the T2WI (arrow) and enhance after contrast administration. On the T1WI the solid vegetations are difficult to observe. Note the characteristic "waist" sign of a dilated fallopian tube (arrow in F). T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Page 38 of 54

39 Fig. 14: Fallopian tube carcinoma. 73-year-old patient with abnormal vaginal discharge. A and B: Photograph of gross specimen of the uterus and the left adnexa of the previous patient demonstrating multiple vegetations in the left fallopian tube which correspond to the fallopian tube carcinoma. A. Félix - Department of Pathology, IPOLFG, Lisbon, Portugal Fig. 15: 63-year-old patient with abnormal vaginal bleeding. Transvaginal ultrasound demonstrated a normal endometrial cavity (not shown) and a right adnexal cystic tubular Page 39 of 54

40 structure (*) with apparent solid content within it (arrowhead). The ovaries were clearly identified. A MRI was advised to further characterize this fallopian tube content. T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Fig. 16: 63-year-old patient with abnormal vaginal bleeding (previous patient). A) Sagittal and (B) axial T2WI; (C) axial T1WI; (D) axial T1 fat saturated MR image after gadolinium. MRI shows a dilated right fallopian tube with hemorrhagic/hight protein content (*) (hyperintense in T1WI) and an enhancing solid mass (arrowhead) suggestive of a right fallopian tube carcinoma, which was confirmed after surgery (serous adenocarcinoma). T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Page 40 of 54

41 Fig. 17: 63-year-old patient with abnormal vaginal bleeding (previous patient). Gross specimen of the right fallopian tube: solid mass with luminal grow causing dilation of the remaining tube corresponding to a serous adenocarcinoma of the right fallopian tube previously described on ultrasound and MRI. A. Félix - Department of Pathology, IPOLFG, Lisbon, Portugal Page 41 of 54

42 Fig. 18: Bilateral hidrosalpinx due and cervical cancer. (A) and (B) axial T2WI showing a slight hyperintense cervical cancer (white arrow) which causes a bilateral hidrosalpinx. Note the "beak" sign (arrowhead) and small plicae in keeping with the dilated fallopian tubes. T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Fig. 19: Peritoneal pseudocyst in 45-year-old woman with left hemicolectomy for colon adenocarcinoma 6 years before. T2WI: Right-sided peritoneal inclusion cyst simulating hidrosalpinx. Note the normal ipsilateral ovary with follicles (arrow) and surrounding loculated fluid conforming to the shape of the peritoneal cavity. The left ovary is also seen. T. M. Cunha - Department of Radiology, IPOFLG, Lisbon, Portugal Page 42 of 54

43 Fig. 20: Mucocele of the appendix in a 66-year-old woman. (A) Axial contrast enhanced CT demonstrating a fluid attenuation tubular structure on the right(*). U - uterus. (B) Axial T1WI and (C) T2WI confirming the fluid filled tubular structure (*) which is similar to a dilated fallopian tube. This structure connected to the cecum making the diagnosis of a mucocele of the appendix very likely. T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Page 43 of 54

44 Fig. 21: Mucinous cystadenoma of the left ovary in a 51-year-old woman with previous histerectomy. Transvaginal ultrasound showing a cystic structure with thin septae inside it (arrow). This lesion was difficult to characterize by ultrasound and a MRI was suggested. T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Fig. 22: Mucinous cystadenoma of the left ovary in a 51-year-old woman with previous histerectomy (same patient as in fig. 22) (A) Sagittal T2WI (B) Axial T1WI (C) Axial T2WI. The lesion observed on ultrasound corresponded to a rounded structure (arrowhead) which contained thin septae inside. T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Page 44 of 54

45 Fig. 23: Paraovarian cyst in a 22-year-old-woman. (A) Sagittal and (B) Axial T2WI; (C) Axial T1WI; (D) Axial T1 fat saturated MR image after gadolinium. A large cystic lesion is observed (*). The ovaries were individualized. This was a large paraovarian cyst. T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Page 45 of 54

46 Fig. 24: Bilateral pelvic lymphoceles after selective lymphadenectomy for ovarian cancer. Axial contrast enhanced CT demonstrates thin walled cystic lesions with fluis attenuation adjacent to the external iliac vessels, with surgical clips in their vicinity The right one being slightly tubular in shape. These are post-surgical lymphoceles. T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Page 46 of 54

47 Fig. 25: Lymphangioma in a 66-year-old woman. A) Transvaginal ultrasound shows a left pelvic thin walled cystic lesion with reticular septations. (B) and (C) axial non-enhanced CT show the same lesion with fluid attenuation (*) adjacent to the left iliac external vessels (arrow). T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Page 47 of 54

48 Fig. 26: 66-year-old patient with endometrial carcinoma and hematometra. (A) Axial T1WI (B) axial and (C) sagittal T2WI show a distended endometrial cavity with blood (*) which simulates a fallopian tube carcinoma. Note the endometrial lesion (black arrow) and the compressed myometrium (white arrow). T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Fig. 27: Hydrometra due to obstruction of the external cervical os. (A) and (B) axial contrast enhanced CT of a patient who presented with pelvic pain. The endometrial cavity Page 48 of 54

49 is distended with low attenuation fluid (*), compressing the myometrium (arrow). This appearance is similar to a dilated fallopian tube. T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Fig. 28: Hematosalpinx caused by non evolutive ectopic pregnancy in a 27-year-old patient. (A) Transabdominal ultrasound showing a cystic lesion with internal echoes (*) (B) axial T2WI (C) axial T1WI (D) axial T1 fat saturated MR image after gadolinium. The hematosalpinx (*) is of intermediate-signal intensity with a high-signal intensity peripheral ring on T1WI and heterogeneous high-signal intensity on T2WI. There is a paraovarian gestational sac-like structure in the adnexa (arrow head) which supports the diagnosis of ectopic pregnancy. The left ovary is seen anteriorly to the fallopian tube (red arrow). (E) Gross specimen. T. M. Cunha - Department of Radiology, IPOLFG, Lisbon, Portugal Page 49 of 54

50 Conclusion During routine clinical practice, radiologists are often confronted with a wide range of pelvic diseases, including pelvic tumors. Sometimes it is not easy to determine the origin of a pelvic lesion and the radiologist must be familiar with the specific radiological signs that suggest a tubal origin of a lesion. It is also important to know the common features of the fallopian tube carcinoma in order to be able to make this diagnosis. Page 50 of 54

51 References Ghattamaneni S, Bhuskute NM, Weston MJ, Spencer JA. Discriminative MRI features of fallopian tube masses. Clin Radiol 2009; 64(8): Sohaib SA, Mills TD, Sahdev A, et al. The role of magnetic resonance imaging and ultrasound in patients with adnexal masses. Clin Radiol 2005; 60(3): Kim MY, Rha SE, Oh SN, et al. MR Imaging Findings of Hydrosalpinx: A Comprehensive Review. RadioGraphics 2009; 29: Rezvani M, Shaaban AM. Fallopian Tube Disease in the Nonpregnant Patient. RadioGraphics 2011; 31: Szklaruk J, Tamm EP, Choi H, Varavithya V. MR Imaging of Common and Uncommon Large Pelvic Masses. RadioGraphics 2003; 23(2): Hosokawa C, Tsubakimoto M, Inoue Y, Nakamura T. Bilateral Primary Fallopian Tube Carcinoma: Findings on Sequential MRI. AJR 2006; 186(4): Benjaminov O, Atri M. Sonography of the Abnormal Fallopian Tube. AJR 2004; 183(3): Outwater EK, Siegelman ES, Chiowanich P, et al. Dilated Fallopian Tubes: MR Imaging Characteristics. Radiology 1998; 208(2): Slanetz PJ, Whitman GJ, Halpern EF et al. Imaging of fallopian tube tumors. AJR 1997; 169(5): Page 51 of 54

52 Personal Information Cláudia Neves Tentúgal Department of Radiology Centro Hospitalar do Barlavento Algarvio Portimão Portugal Teresa Margarida Cunha: Department of Radiology Instituto Portugues de Oncologia de Lisboa Francisco Gentil Lisboa Portugal Ana Félix Department of Pathology Instituto Portugues de Oncologia de Lisboa Francisco Gentil Lisboa Portugal Page 52 of 54

53 Images for this section: Fig. 29: Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon Portugal Portuguese Oncological Institute of Lisbon Page 53 of 54

54 Fig. 30: Centro Hospitalar do Barlavento Algarvio, Portimão, Portugal Centro Hospitalar do Barlavento Algarvio, Portimão, Portugal Page 54 of 54