Challenging Ultrasound OB/Gyn Cases - SD

Introduction

Hi, I'm Christus Loki.

I'm a member of the abdominal imaging section at the NYU Langone Medical Center in New York City.

What I'd like to do is to share some challenging diagnoses that my colleagues and I have encountered in the course of our work in imaging the female pelvis.

First Patient: 3-Year-Old Woman with Vaginal Bleeding

Our first patient is a 3-year-old woman who presented to the emergency room with extensive vaginal bleeding, cramping, and a prior syncopal episode and had a hematocrit of 27%.

These are the initial transabdominal images that were obtained.

These are the endovaginal images and the ultrasound findings ask what is within the endometrial cavity, what is expanding the endometrial cavity, and what is this spongiform hypervascular area in the uterine fundus represent?

What do the color and spectral doppler tracing show and what would you recommend next, if anything?

We had a diagnosis proposed and an MRI was performed, which showed multiple flow voids in the area of the uterine fundus.

The post gadolinium images showed brisk enhancement of these abnormal vessels in the myometrium with extension to the submucosa and the mucosa layer.

There was a uterine arteriovenous malformation with early drainage into the right hypogastric vein.

This is an image with a patient treated with embolization, with a small volume of NBCA adhesive showing the final result where the AVM was successfully embolized.

This was uterine arteriovenous malformation.

These are very rare in non-pregnant women, and were first described in 1926.

Arteriovenous malformations can be congenital or acquired and have been reported over a wide range of ages.

Most congenital uterine AVMs are isolated anomalies, but can occur in association with AVMs at other sites, they have multiple vascular connections and tend to invade the surrounding structures.

When they're congenital, they're believed to result from arrested vascular embryologic development and bleeding is the major presenting symptom in AVMs.

Acquired causes are numerous, and I think the most common would be a previous pregnancy.

Here, we show an AVM post-termination of pregnancy, which resolved spontaneously and has features that are similar to the congenital AVM showed.

However, the vascular structures were not as prominent, and the management depends on presentation, location and the need to preserve fertility.

The options can be conservative, surgical, or as in our patient endovascular.

Second Patient: 41-Year-Old Pregnant Woman with Adnexal Mass

The second patient is a 41-year-old woman, 18 weeks pregnant with ongoing left-sided pain throughout pregnancy and was found to have a large left adnexal mass.

These are the images of the live fetus, and in the left adnexa, you can see this very large, up to 15 centimeters by lobed mass.

The superior component of the mass, if you look at it, really reminds you of a mature cystic teratoma with cystic components as well as these shadowing echogenic foci.

However, the inferior component of the mass is solid and vascular and shows no demarcation with the dome of the urinary bladder and endovaginal images were obtained and we were sure that we were in the urinary bladder by showing the urethra, and there is extensive debris within the urinary bladder.

When we extend to the dome of the urinary bladder, we see soft tissue with associated vascularity, which confirmed involvement of the urinary bladder by this mass.

The patient had undergone an MR at an outside hospital from which she was referred.

These are the sequential coronal T two weighted images showing invasion of the urinary bladder.

There was also some question of invasion of the myometrium, however, because of the lack of gadolinium administration, this could not be confirmed.

The intraoperative findings showed a large left ovarian mass with extensive surrounding adhesions.

The solid component involved the urinary bladder dome.

There was however, no myometrial extension and surprisingly the initial frozen section was indeterminate, with a finding of either malignant degeneration of a teratoma or inflammatory pseudotumor.

However, the final diagnosis was concurrent with our initial diagnosis, which was malignant degeneration of a teratoma into a squamous cell carcinoma within the solid component.

This is a CT image, which shows the same process in a different patient.

Malignant degeneration occurs in approximately 2% of mature cystic teratoma and differentiated tissue give rise to either sarcoma or carcinoma.

The most common degeneration is squamous cell carcinoma arising from the squames of the cyst.

It usually occurs in women a bit older than our patient in the sixth and seventh decade of life.

The preoperative diagnosis is difficult in absence of either metastasis as shown in this peritoneal implant or local extension as shown by this extensive extension into the adjacent small bowel loop.

Third Patient: 34-Year-Old Pregnant Woman with Right Lower Quadrant Pain

Our third patient is a 34-year-old woman with acute right lower quadrant pain without leukocytosis or fevers, and the patient is 32 weeks pregnant.

These are the transabdominal ultrasound images, which are high up in the pelvis anteriorly and laterally.

The ultrasound findings show an enlarged right ovary with multiple cystic components, as well as this central echogenic component.

No blood flow could be delineated and the mass corresponded to the area of the patient's pain.

The left ovary was also evaluated, was also enlarged, and showed a large solid echogenic component flow was seen along the periphery of the ovary.

Upon further questioning, the patient reported prior surgical removal of a dermoid, but was not really sure which side the operation had involved.

Our assessment was torsion of a right ovarian mature cystic teratoma.

However, the clinicians did not feel that the clinical picture was consistent with torsion.

The patient underwent a CT scan to evaluate for appendicitis at the request of the clinical team.

Here are the CT images both in axial and coronal projections.

Note the bilateral dermoids, the appendix, which is not visualized, not shown here, was normal.

Notice how superiorly displaced this right ovary, both ovaries are, but the right ovary is almost touching the liver.

The patient finally did go to laparotomy and because of her advanced pregnancy, this needed to be done as a laparotomy and the right ovary was found to be enlarged and necrotic.

On histologic examination was a necrotic mature cystic teratoma, and the vascular pedicle was twisted five times.

The take home messages, don't forget to routinely image the ovaries in pregnancy and the sooner in pregnancy that you image them, the better, this patient was in the third trimester and had had several prior imaging.

However, the adnexa had not been interrogated.

Fourth Patient: 65-Year-Old Woman with Elevated CA-125

This is a 65-year-old woman who's had TAH-BSO for fibroids eight years ago.

She had just completed treatment for invasive ductal carcinoma of the breast six months ago and is currently in remission and was incidentally found to have a tenfold elevation of a CA 125 and was asymptomatic.

Starting with the transabdominal images, we already see that there is some abnormality in the cul-de-sac, and these are the endovaginal images showing a large, up to 5.6 centimeter complex mass.

The mass shows both solid and cystic components, and the ultrasound findings were felt to be compatible with a vascular mass that had the sonographic appearance of a primary ovarian neoplasm.

However, the ovaries and uterus were not visualized compatible with the patient's history of a prior TAH/BSO the CT findings, there was no ascites or omental nodularity, no associated adenopathy or, and no cite to suggest serosal implants.

So the findings appeared to be limited to the pelvis.

On histopathologic examination, this was an extra ovarian primary peritoneal carcinoma.

The first case of this entity of primary peritoneal carcinoma was reported in 1959, and at that time, a 27-year-old woman had a papillary serous carcinoma of the peritoneum with no ovarian involvement.

This is an unusual and rare entity.

It has many associated names, although the precise causes are not known, there is a link between a certain variance of the BRCA gene.

Furthermore, women with the BRCA mutation have a 5% risk of developing this primary peritoneal carcinoma even after prophylactic oophorectomy.

The epithelial layer of the ovary and the peritoneum share a common embryologic origin so that this entity acts as ovarian carcinoma would at spreads intraperitoneal.

If the ovaries are involved, they are only involved by surface involvement.

The therapy is that of ovarian carcinoma.

Fifth Patient: 52-Year-Old Woman with Vaginal Bleeding and Leg Swelling

Our fifth patient is a 52-year-old African-American woman with one month of vaginal bleeding and recent right leg swelling.

These are the transabdominal images in long.

You see these multiple specular reflectors, which are compatible with air as well as several cystic foci.

You see a very attenuated wall of the uterus, which is very enlarged.

Also notice the extensive adenopathy in the right adnexa and along the right pelvic sidewall, which accounted for the patient's physical findings of the right leg swelling.

This is a limited transvaginal examination of the cervix, and you see extension of the mass into the endocervical canal.

The patient underwent a CT scan and there is associated retroperitoneal adenopathy, further superiorly in the abdomen.

Again, the right pelvic sidewall adenopathy that we saw on ultrasound.

This is a malignant mixed mullerian tumor, which is a carcinosarcoma.

This usually presents as a heterogeneous mass expanding the uterus, and it often protrudes through the cervical os, as the diagnosis.

The diagnostic clue is that this is a broad base large uterine mass with aggressive myometrial invasion.

The differential diagnosis is that of endometrial carcinoma, MMMT sarcoma, or an endometrial stromal sarcoma.

Companion Case: 24-Year-Old Woman with Vaginal Bleeding

As a companion case, this is a 24-year-old woman who's presented with profuse vaginal bleeding.

Stated that her LMP was three months ago prior with ongoing intermittent bleeding.

In all fairness, I'm withholding some clinical data, and these are transabdominal views of her uterus, which is also expanded by heterogeneous soft tissue.

Both of the ovaries are normal.

These are the endovaginal images, and again, we have multiple specular reflectors.

However, these show shadowing that is not quite the specular reflectors that we saw in the previous patient and flow is seen only in the peripheral myometrial vessels.

In this patient, the quantitative beta HCG is 444.

The patient underwent endometrial cure and the pathology showed degenerated fetal membranes and chorionic villi.

The chorionic villi had extensive stromal fibrosis and calcification along, involving the trophoblastic layer and were avascular precluding estimation of the gestational age.

You can see this calcified layer at the junction of this abnormal soft tissue within the endometrial cavity and the myometrium.

Even though the sonographic findings may be similar, the imaging findings need to be interpreted in the clinical context.

Sixth Patient: 30-Year-Old Woman with Enlarging Ovarian Mass in Pregnancy

This is a 30-year-old woman followed serially for an enlarging left ovarian mass throughout pregnancy.

At 15 weeks gestational age, we have the left ovary here, it measures approximately 3.7 centimeters.

You can see that with advancing gestational age, the left ovary becomes more and more complex in appearance and is larger.

This is at 33 weeks gestational age.

This was a decidualized endometrioma.

Endometriomas may become decidualized during pregnancy resulting in solid vascular areas that may mimic an ovarian carcinoma.

Fortunately, this is a rare occurrence and awareness along with MR evaluation and follow-up imaging may facilitate the appropriate diagnosis.

Also, this is another reason to know what the patient's ovaries look like early on in pregnancy.

If you know that the patient has had an endometrioma and you're aware of this potential complication during pregnancy, you would feel more comfortable following this patient throughout pregnancy rather than intervening surgically.

MR is useful because the MR signal of the decidua in the uterus is the same signal as the decidualization seen within the ovary.

Seventh Patient: 37-Year-Old Woman for Cesarean Section with Placenta Previa

Our next patient is a 37-year-old woman, admitted for her sixth elective cesarean section, and she's had prior imaging at an outside facility that showed a placenta percreta at 21 weeks confirmed at 31 weeks.

She was referred to us for amniocentesis for fetal lung maturity, which was performed at 36 weeks, six days.

The following are the ultrasound images, which were obtained at the time of the amniocentesis.

We see this very large placenta previa.

This is the baby's head, and along with the placenta previa, there are these large venous lakes.

There's extensive vascularity, which invades the anterior lip of the cervix.

This is the urinary bladder.

These low resistive placental vessels come up to the serosa of the urinary bladder.

The fetal lung maturity was positive and the patient was scheduled for a cesarean hysterectomy the next day.

At that time, her hematocrit was 33.

On the day of surgery, an epidural catheter was placed.

She also underwent interventional radiology balloon placement in the bilateral proximal internal iliac arteries.

That is shown here with the balloon positioning and inflation of the balloons.

She underwent intraoperative cystoscopy with placement of bilateral ureteral stents, and the cystoscopic evaluation showed marked hyperemia due to the submucosal vessels, but there was no penetration of the mucosa by the placental tissue.

The patient's operative course was quite long and stormy.

She had dense adhesions between the bladder, the placenta, and the lower uterine segment with placental invasion through the lower uterine segment and serosa involving the bladder.

The left aspect of the placenta was adherent to the bladder, and a classical uterine incision was performed above the placenta.

A viable male infant was delivered with good apgars and the hysterectomy was started.

This is the intraoperative view.

As I said, the operative course was quite stormy.

The internal iliac balloons were inflated.

The patient underwent a retrograde installation of sterile milk into the bladder, which showed an two centimeter cystotomy in the left dome at this time.

The patient was intubated, a supracervical hysterectomy was completed, and then bleeding was noted from a barren vasculature from placental adhesion.

A second surgeon was called in and the patient became hemodynamically unstable and intraoperatively, the patient underwent emergent embolization of the internal iliac arteries.

This is the post embolization angiogram.

The goal of this is for rapid permanent embolization of the proximal hypogastric arteries.

This shows the surgical specimen with these aberrant vessels noted, and this is a view of the amputated cervix.

All in all, the patient received 26 units of packed red blood cells, 40 units of platelets, 11 units of FFP and 11 units of cryoprecipitate.

However, the patient was discharged home on postoperative day six with two Jackson Pratt drains and a Foley catheter bag.

On postpartum follow up. All of these were removed and she did well.

Here we're dealing with placenta accreta or increta or percreta, and we know that the risk factors are previous uterine surgery and the risk of accreta rises dramatically with the number of prior cesarean sections.

The complications are transfusion, infection, perinatal death, maternal death, ureteral ligation, or fistula formation, or spontaneous uterine rupture.

The mainstay of treatment remains cesarean hysterectomy.

However, a multidisciplinary team approach is essential to reduce neonatal and maternal morbidity and mortality.

As was seen in this patient, there have been some scattered reports of methotrexate use.

However, most of these experienced significant delayed hemorrhage.

So at this time, there's insufficient evidence demonstrating safety and efficacy of methotrexate use.

Eighth Patient: 38-Year-Old Woman with Postpartum Complications

Our eighth patient is a 38-year-old woman who's had a normal spontaneous vaginal delivery in December oh nine.

This was followed by a DNC two months later because of continued postpartum bleeding and the beta HCG was negative.

This is the appearance of the placenta at 33 weeks gestational age, which shows your mature placenta with calcifications.

The pathologic report at delivery of the placenta was a three vessel cord and fetal membranes, no pathologic diagnosis.

The placenta was noted to be a third trimester placenta with some increased intervillous fibrin, increased syncytial knots and microcalcifications.

This was the ultrasound two weeks following the initial DNC when the patients had continued postpartum bleeding and pain.

These are the ultrasound images showing this calcified densely calcified material within the endometrial cavity.

Our assessment at this time was, what would you check at this point?

Does a negative beta HCG exclude a postpartum complication?

We went back and looked at the pathology at the initial DNC prior to our ultrasound, and the diagnosis was products of conception with hyalinized and calcified chorionic villi and decidua consistent with retained products of conception.

We were pretty confident that we were dealing with retained products of conception.

This was the ultrasound following the second DNC where we had still residual calcification outlining the endometrial lining.

Our assessment at this point, or our thoughts at this point was, was there an accessory placental lobe, which was overlooked prenatally?

On the prenatal evaluation, don't forget to look for possible accessory placental lobes.

Ninth Patient: 50-Year-Old Woman with Vaginal Bleeding

A 50-year-old woman with vaginal bleeding and clinical concern for cervical carcinoma.

Her clinical history is that of placement of an IUD 20 years ago.

These are the initial transabdominal images.

Note this hypoechoic mass in the region of the cervix.

These are the transvaginal images.

Does this mass remind you of anything?

When I see something that reminds me of something else, I start to approach that patient in that manner.

Is this something usual in an unusual place?

The other finding is, we see a portion of the patient's intrauterine device, which was clearly seen on these correlative CT images, which were done to evaluate for possible metastatic disease.

The patient did undergo a hysterectomy for possible cervical carcinoma.

However, the pathology revealed endometriosis involving the cervix with an endometrioid cyst.

This is the pathologic specimen.

Here you see the endocervical canal, the external cervical os, and here is the endometrioid cyst involving the cervical stroma.

When I first looked at this image, it reminded me of an endometrioma.

Cervical involvement by endometriosis is very uncommon.

It may be an incidental microscopic finding.

It may arise in a polypoid mass arising from the cervix, but it also may cause abnormal vaginal bleeding.

There's often a history of prior cervical trauma, either curettage or biopsy.

This patient had an IUD placed.

So there's a question of implantation of endometrial fragments, or does this result from endometrial implants, which persist in the cervical stroma?

These are all possibilities as to the etiology.

Tenth Patient: 54-Year-Old Postmenopausal Woman with Pelvic Mass

Our next lady is a 54-year-old woman who postmenopausal, noted to have a pelvic mass on physical examination.

Here we see a cul-de-sac mass.

Our question is, is this attached or separate from the uterus?

There was an atrophic right ovary, but no left ovary was seen.

It would make a difference if this arose from the uterus or whether this arose from the left ovary.

We're fortunate in ultrasound to be able to manipulate our examination.

Here we see that the mass is clearly separate from the uterus.

There are no bridging vessels between this mass and the uterus.

We concluded that this is a cul-de-sac vascular mass, predominantly solid with some scattered cystic areas.

It's separate from the uterus and therefore presumably, of left ovarian origin.

I would just point out that the endometrial lining was atrophic.

This CT was performed and the mass was interpreted as being a fibroid or a fibroma.

Patient underwent resection of the cul-de-sac mass.

This was an endometrioid carcinoma of the left ovary.

This is a subtype of epithelial ovarian neoplasm.

It's the third most common ovarian malignancy.

After serous and mucinous cystadenoma, it can have mixed, solid and cystic components.

Interestingly, endometrial hyperplasia or carcinoma is seen in approximately a third of the patients as an independent primary tumor rather than a metastasis.

In younger patients is important to remember that this is the carcinoma that can arise within an endometrioma.

Eleventh Patient: 29-Year-Old Woman with Enlarging Pelvic Mass

A 29-year-old woman with an enlarging pelvic mass.

These are the transabdominal images.

You can see that this is a very heterogeneous vascular mass, but in contradistinction to the patient that we saw before, we don't really see the myometrial wall here.

However, the ultrasound was interpreted as representative of a large neoplasm of the endometrium.

The patient, however we found out, had had an MRI at an outside institution from which she was referred.

These are the gadolinium enhanced sequential T one weighted images.

What did the MRI show that the ultrasound didn't and how did it change our diagnosis and did it affect our surgical planning?

Here we see the uterine corpus, and this is the uterine corpus is deviated all the way to the right by this large mass.

It was not visualized on the ultrasound.

The mass actually arose laterally from the fundus of the uterus.

Therefore uterine sparing resection of this mass was performed.

This is a very unusual entity.

It's a low grade leiomyosarcoma, which was thought to arise within a leiomyoma.

The tumor was ERPR positive leiomyosarcomas usually arise from the myometrium itself or smooth muscles of the myometrial vessels.

Malignant degeneration of a fibroid is extremely rare.

Any rapidly enlarging uterine mass is a clinical clue for a leiomyosarcoma.

Twelfth Patient: 24-Year-Old Woman with Purulent Vaginal Discharge

24-year-old woman with purulent vaginal discharge.

We are to evaluate her for possible pelvic inflammatory disease.

These are the transabdominal images.

I bring your attention to the midline trans images, which show two uterine corpuses.

What are the ultrasound findings?

The ovaries are normal.

The vagina is filled with fluid in debris.

Actually one of our the sonographer actually thought this resembled a crown rump length and perhaps the patient was aborting, but whoever the patient was, beta HCG negative.

Are we dealing with a uterine anomaly?

If so, what kind and what else would we like to image?

We know that there's a correlation between pelvic abnormalities and renal abnormalities.

In this patient the right kidney is enlarged and the left kidney cannot be located.

Upon further questioning, the patient relates a history of dyspareunia.

A diagnosis of uterus didelphys with an obstructed hemivagina with possible incomplete septum was proposed.

What we recommended next was an MRI, which is very helpful in delineating these pelvic congenital anomalies.

Here we see the uterus didelphys and this MRI was performed a little bit differently than the normal protocol.

The patient self inserted lube into the patent right hemivagina for better expansion and conspicuity.

This was the left blind ending obstructed hemivagina.

On other images, the wall of the obstructed left hemivagina enhanced due to the presence of chronic inflammation.

Our final diagnosis was uterus didelphys, left renal agenesis, a blind ending obstructed left hemivagina and vaginal contrast allowed for better delineation of both vaginal canals.

Also showed us a small communication between the obstructed hemivagina and the patent hemivagina.

This likely accounted for the lack of hematometra in this patient.

This has a long name.

This is the Herlyn-Werner-Wunderlich syndrome, which basically is a uterus didelphys with an obstructed hemivagina and ipsilateral renal agenesis.

This is rare, it usually presents after menarche and the patient presents with progressive pelvic pain and there can be hemimetra or hemihydrometra, and it's treated with a vaginal septectomy and drainage of the hematocolpos or hematometra.

I'll leave you these for a discussion of the mullerian duct abnormalities which develop from the embryonic mesoderm.

This is just for your perusal.

Thirteenth Patient: 37-Year-Old Woman with Increasing Abdominal Girth

This is a 37-year-old woman who presents with increasing abdominal girth.

These are representative images through the abdomen.

I'll bring your attention that this is the coronal views of the aorta and the cava.

This is the aorta here and the IVC.

This is a view of the pancreas, and these are images of the right ovary.

These are the images of this material that was seen within the abdominal cavity.

These are the correlative CT images.

You see how much less tissue differentiation you see on CT scan because CTs basically just measures density.

All of this really measures soft tissue or water density.

So you don't really get the exquisite architecture that you do with sonography.

This is pseudomyxoma peritonei of ovarian origin, which is a rare condition, and it's due to mucinous cystadenomas with peritoneal and omental implants.

It's caused by seeding of the peritoneal cavity by mucin producing cells.

The organ of origin is usually the appendix or the ovary.

The mainstay of treatment is surgical debulking.

The recent use of heated intraperitoneal chemotherapy at the conclusion of a surgery has been quite helpful.

There the surgeon puts on these big rubber gloves and tries to distribute chemotherapy throughout the peritoneal cavity.

The ultrasound is really quite typical shows these echogenic, poorly mobile ascites.

This is the patient post-surgical debulking and heated intraperitoneal chemotherapy.

Fourteenth Patient: 35-Year-Old Woman with Right-Sided Pain and Positive Beta HCG

35-year-old woman with right-sided pain and a beta HCG of 154.

She states that her LMP was six weeks ago, and we see this is an enlarged myomatous uterus.

There's no IUP and the right ovary is really not clearly delineated transvaginally And even this portion of the ovary that was presented looks a little bit suspicious, with this echogenic ring in it.

We repeated the transabdominal examination and here in the right interstitial portion of the uterus we see an echogenic ring.

It is clearly separate from the right ovary.

On this clip you can see that here's the echogenic ring.

It's connected to the interstitial portion of the uterus.

It is clearly separate from the right ovary, and this is a right interstitial ectopic.

Do not overlook the value of transabdominal imaging, especially if you're dealing with an enlarged uterus and you cannot, there's a high clinical suspicion of an ectopic pregnancy, so don't overlook the possibility of an interstitial ectopic pregnancy.

Fifteenth Patient: 29-Year-Old Woman with Left Lower Quadrant Pain

This is our last patient, a 29-year-old lady with schizoaffective disorder and left lower quadrant pain.

A pelvic ultrasound was performed, the right ovary was normal.

The uterus and endometrial lining was normal.

However, no normal left ovary was seen.

Here are the adnexal findings.

Here we see the normal right ovary and we see that the left ovary has this tear drop shape.

There's a vascular pedicle adjacent to the left ovary.

However, we don't see any flow within the left ovary.

It's in the expected location of the left ovary, and the right ovary is normal.

What do you consider at this point?

Is this a tumor, is this abscess an ectopic kidney?

Something else.

This patient because of her coexisting schizoaffective disorder three weeks previously had, prior to this ultrasound, had undergone a CT scan for evaluation of urinary tract calculi and no abnormality was reported.

Do you agree and I just bring to your attention this structure here to keep in the back of your mind.

11 days following the CT, the patient had undergone a pelvic MRI and a diagnosis was proposed.

We see a normal right ovary, but what is going on with this left ovary?

This is a nice sagittal HASTE view of the left ovary.

Here are all three imaging modalities together.

What this was is a chronically torsed left ovary with coagulative necrosis and the delay in diagnosis here was related somewhat to the patient's comorbid disease.

She had refused to come down for imaging several times and it just brings out the difficulty in dealing with patients who do have this comorbidity.

Conclusion

I thank you for your attention and I hope that I've showed you some challenges related to diagnosis, the value or limitations of correlative imaging management technique and psychosocial factors.