Challenging Cases - HD

Introduction

I'm Sheila Sheth.
I'm a body imager at Johns Hopkins.
And today I'm going to show you some challenging cases.
This is not a specific topic.
I'm just going to show some cases that we've been struggling with and maybe you will.
And then after each case, we'll pause.
We did give you a few seconds to think about what you would do, and then we proceed on discussing the cases.

Okay, so let's get started.
As I said, these are challenging GU cases.
You'll see some urinary cases and some pelvic cases.

Case 1: Epidermoid Cyst in the Testicle

Our first case is an anatomy.
It's actually case number zero, and this is a 30-year-old man who presented for a scrotal ultrasound because there was a mass.
I'm showing you two images of this mass here and you see a well circumscribed mass.
Okay? And just to give you a few minutes to think, a few seconds to think, what do you think it could be, and what do you think the management would be for this patient?
Does he need a radical orchiectomy or does he need enucleation?

If we look at it, this is actually anatomy, right, because it has a it's very well marginated.
I did not give you a doppler, which I think would be useful information, but there was no flow on the color doppler.
And you see this kind of alternating echogenic rings here, the onion ring appearance, okay?
I'll give you another example of this entity, perhaps even more classic.
This patient had two of them.
But this one was very classic.
This alternating very well-defined mass with this echogenic rings that have been likened to onion rings.
And so this is basically an epidermoid cyst, at least.
This definitely is a good example of an epidermoid cyst in the testicle.
So this is one of the uncommon intrascrotal mass that is benign.
And what they consist of, there is fibrous tissue lining the cyst wall, and there is an inner lining of squamous epithelium.
And because of the squamous epithelium, the cyst wall are filled with cheese-like material, which is keratin.
So they present as a well-defined intratest mass with this onion ring appearance.
So what you do for these patients when we've had several of them, is check the tumor markers, of course, to make sure that they're all normal.
And the management, if it's a classic case, can be enucleation to avoid radical orchiectomy.
Or some patients even are we have one or two patients in our unit that are carefully followed.

Uterine Sarcomas

Now let's start with a more complex cases.
The first patient, and I have two patients in this category.
The first case one a he said, of a 36-year-old woman with a diagnosis of uterine fibroids, which is already made, who presented with severe lower abdominal pain and profuse vaginal bleeding.
So here I'm showing you two transabdominal images.
A sagittal image of the uterus and uterus measures 20, almost 24 centimeters by 14 centimeters.
Transverse images of uterus fundus here, and just a clip.
So you get a sense of the appearance of these pelvic mass and the vaginal ultrasound, because a mass is so big was not really contributory.
And so on ultrasound, what we said is this is a markedly enlarged fibroid uterus.
She's young, she has vaginal bleeding.
So the patient came back to our emergency department a few weeks later, and this is what she, and she had a chest CT because she presented with intractable cough.
And this is a CT I'm showing you after actually she had a biopsy.
But you can see here that she has a pneumothorax, which is likely post-procedural, but she has multiple pulmonary masses, okay?
And the biopsy of one of these masses showed atypical spindle cells favoring the diagnosis of leiomyosarcoma.
She then had a pet CT and CT and pet CT for staging.
And you can see here that the uterus is very big.
The large masses are only lower attenuation because they're necrotic, but there's a whorl of enhancing tissue at the edge of the larger mass, a whorl of pet activity at the edge of the mass right here.
So she did have a chest tube for her pneumothorax.
She was treated with chemotherapy, with gemcitabine and docetaxel.
She had preoperative uterine artery embolization, and then she had a TAH-BSO, which confirmed the diagnosis of leiomyosarcoma.
Unfortunately, the patient subsequently had progression of pulmonary metastasis with recurrent pneumothorax and brain metastasis.

What about this case? Another very young woman, 29 years old, who had presented to the emergency department with severe menorrhagia to the point that her hemoglobin was only four and she had a negative beta HCG.
So here's what her pelvic ultrasound look like. Okay?
I'm showing you transabdominal ultrasound.
Initially, the uterus is quite large and there is what appears to be a complex tissue.
Some of it is cystic, some of which is solid within what looks like the endometrial cavity with increased vascularity.
So of course, we're gonna do an endovaginal ultrasound for better evaluation.
Whether it helps a lot or not, I'm not sure, but basically the endovaginal ultrasound confirmed the fact that there was some intraendometrial, what looked like an endometrial mass.
I think it's better seen actually, if I go back on the transabdominal ultrasound, you get a better sense what's going on in the uterus, again, because uterus is large and the relatively limited field of view of endovaginal ultrasound.
And so on ultrasound. And if you look at the ovary, there are multiple follicles.
They're peripheral, they're pearl like, they're more than 12.
And so on ultrasound, we read it as suspicious for endometrial cancer despite this patient's young age, which obviously would be atypical.
She also likely we said, had polycystic ovaries.
And of course, patients who have polycystic ovaries because of the unopposed estrogen have a slightly higher risk of endometrial cancer, but perhaps not at age 29.
And then we recommended an MR.
And so an MR again, you see on the contrast that was a non-contrast, and this is a SAG T two.
Here you see an enhancing mass, a large mass within the endometrial cavity, which is enhancing, with more than 50% invasion of the myometrium we a likely an endometrial cancer based on imaging appearance.
And again, the MR nicely shows the ovaries with multiple peripheral cysts.
And there was also some lymph node that appeared to be suspicious.
So the patient had a TAH-BSO and pathology.
What this turned out to be was a primitive neuroectodermal tumor, a PNET of the uterus, of course, a very rare tumor.
She also did have bilateral polycystic ovaries.

So could we have made the diagnosis prospectively on any of this patients?
Well, the first patient, I think the vast majority of the time would still say this is a very enlarged fibroid.
In the second case, we would obviously be concerned about endometrial cancer, but uterine sarcomas is a very difficult diagnosis to make.
They're first of all uncommon, they only represent three to 8% of uterine malignancies, and they have a very protean appearance.
So they have their clinical presentations very nonspecific and basically mimic uterine fibroids or endometrial tumors.
The vaginal bleeding can be very profuse.
The patient can present with pain or uterine enlargement.
And there are several variety of uterine sarcoma.
The most common are the pure mesenchymal tumors such as leiomyosarcoma, which represent about 40% of uterine sarcomas.
You have endometrial stromal tumors.
You have the mixed epithelial and mesenchymal tumors, which represent 40% of the so-called sarcomas.
The MMMTs, which actually are probably are likely an aggressive form of endometrial cancer.
And then very rarely you have these PNET, which are blue cell round tumor of the uterus.

So this is another exam.
This is an example of a carcinosarcoma, or this mixed mullerian tumor of the uterus.
This is in, they typically present in older women.
The patients present with postmenopausal bleeding.
This is a patient who had a large uterus.
A 17 centimeter uterus is way too large for a woman who is 76 with a mass, which looks like within the endometrial cavity.
Here's the CT scan.
Not very helpful actually, but you can see that there is a very large mass within the uterus here, probably a little bit of air because the patient had a biopsy, and this was a carcinosarcoma, which are now considered to be a very aggressive form of endometrial cancer.

So again, as I said before, uterine sarcoma are very difficult to diagnosis to make prospectively because they mimic very large fibroids on imaging.
If you're suspecting it, MR definitely is the best imaging modality, in sarcoma is the endometrial biopsies often negative.
What we have to actually think about uterine sarcoma is if there is a very rapid uterine enlargement or if there is a very large bulky uterus in an elderly woman, or of course, and we should look for it when we do the ultrasound.
If there are metastatic lymph nodes or the patient had nodules such as lung metastasis obviously.
And again, in these patients, MR is the best imaging modality.
And then CT use is used for staging to look for liver, pelvic lymphadenopathy and peritoneal nodules.

So this is another example of leiomyosarcoma.
This was a 68-year-old woman, which postmenopausal bleeding.
We had a negative endometrial biopsy because these tumors are actually in the myometrium.
So you can see, again, a very large uterus, 18.8 by 12 centimeter in a postmenopausal woman with what looks like endometrial, uterine masses just based on the ultrasound appearance.
It's really hard to say what's going on, but you'd be suspicious because the size of the uterus in the elderly woman.
And when we looked around further in the pelvis, and you should be always doing this, she had this kind of abdominal mass or omental mass here.
And of course then you become very suspicious that this is a malignant lesion.
At least you could say that.
And this turned out to be a high grade sarcoma.

So what is a differential diagnosis in patients who have marked uterine enlargement?
First of all, as I've hoped to show you, to get a full picture of what's going on their best image by transabdominal ultrasound.
And because the mass, the uterus is enlarged, it will displace the bowel.
And so you don't really need to have a full bladder.
So the differential diagnosis, of course, the most common is still a uterus, and the fibroids can enlarge a little bit, especially around age 40 to 50.
But if there is rapid enlargement or very significant enlargement, then definitely you should raise as possibility and the patient would benefit for his from a hysterectomy.
Adenomyosis can cause uterine enlargement, not definitely not to the same degree as sarcomas.
Think about leiomyomatosis or metastasomas.
Think about what I've shown you malignant uterine tumors of the myometrium uterine sarcomas, which as we talked about, all these already rarely think about metastatic disease or lymphoma, very uncommon.

So this is an example of a patient who had regular CT scan follow up for her breast metastatic breast cancer.
And about six months prior to this CT scan here, she had a normal appearing uterus on her ct.
And now on the sagittal reconstruction, you can see uterus is enlarged and is very heterogeneous enhancement of the ct.
So based on that, she also had an ultrasound that basically shows an enlarged uterus, very heterogeneous, kind of bizarre looking.
These are not really discrete masses, but just very heterogeneous myometrium with hypervascular.
And this we presume is metastatic breast cancer because of the we had a baseline ct.
So it's much easier obviously to think about that diagnosis in this case.

Case: Retained Surgical Sponge

Okay, so my next case is a case, and some of the cases I'm showing are really cases we struggled with, or we did not make a correct diagnosis.
I'm hoping that everybody can learn from that.
So this is was a 26-year-old woman who was in the third trimester of pregnancy and was referred to us because she had a left upper quadrant mass.
And so the first thing we do, she was pregnant, so we did an ultrasound and the region of the mass in the left upper quadrant, we saw this here.
So we saw this kind of hypoechoic mass with maybe some areas of shadowing, very little flow, a little bit of flow, not much.
And this mass we thought was separate from what we thought was the gravid uterus, but could still, and that's what we thought about would be considered a pedunculated fibroid.
Consider the possibility of sarcoma.
This was our report, indeterminate complex mass, consider fibroid or sarcoma.
So what we could tell by the ultrasound is that the mass was separate from the spleen and we thought probably separate from the liver.
So then the patient had an MR, and again, so this is the gravid uterus with a fetus here, but you can see in the area of the mass, here's the mass.
And this is how the MR was read, no connection with the uterus or liver.
Consider exogastric or duplication cyst.
The patient did not have, did not get contrast because she was pregnant so she could not get gadolinium.
So the patient was on the third trimester of pregnancy.
So after delivery, she had a ct.
And the mass, of course was still present.
You can see it here.
And again, you can see that it's separate from the liver, could it be attached to bowel, possibly separate from the spleen.
And this is what it looks like.
So the areas of enhancement, we're not too sure.
Here's the coronal reconstruction and our coronal construction that maybe it's coming on exogastric from the left hepatic lobe.
So this is how the CT was read, possible hepatic adenoma with bleed, possible GIST tumor, a gastrointestinal stromal tumor, or mesenteric mass.
So then the patient came to biopsy.
So this is what happened.
So then the patient came to biopsy and I did it myself.
I remember that we did multiple core biopsies in this mass.
And the pathology diagnosed very disappointing because it's a non, essentially non-diagnostic with blood scatter spindle cell and giant cell and associated with polarizable suture material.
So she went to surgery and with a pre-op diagnosis.
So I guess guess nobody read this pathology report very carefully.
The pre-op diagnosis was still GIST.
And that surgery, they found a large left upper quadrant mass, removed it at frozen section.
This was a retained sponge.
And the patient, because of the extent of the surgery, ended up having a partial gastrectomy and hepatectomy.
So the key element of the history that really nobody asked for, and nobody even thought about, was that the patient had on in during the course of a previous pregnancy, she had surgery for acute appendicitis with a prolonged postoperative course.
So this is really a case where all of us were completely not on the right path for diagnosis.

So this is actually not always an easy diagnosis of retaining intraabdominal sponge or also called gossypiboma.
So unfortunately, it's fortunately a rare complication, perhaps one in 1000 to one in 500 intraabdominal surgeries.
Typically, this is gonna be difficult surgery, emergency surgery, obese patients, and they may be relatively asymptomatic and presents several years later after surgery.
And so therefore we forget the initial history of a difficult surgery.
The patient may present with intra intestinal obstruction or have an intraabdominal abscess, and of course the complications or a lesions infection and fistulization.

So this is maybe a more classic example of a retained sponge because it has this, so it's a relatively well-defined lesion containing all this gas here.
But you have to be very careful and something that we always to think about because if you're not careful and you don't realize that at the edge of the mass there is this radiopaque line, which are the radiological marker, you could confuse this for just a simple abscess or worse mistake for a loop bowel.
So you really have to be attuned to the possibility, the rare possibility of this diagnosis.
And of course, never forget to look at the scout, because on the scout you can see that this is actually the radiopaque marker marking the sponge, a surgical sponge.

Case: Varicocele and Retroperitoneal Sarcoma

Okay? So this is a case where I give all the credit to one of our very excellent sonographers who was called to the emergency department to do a scrotal ultrasound on a 37-year-old man who presented with scrotal swelling and left scrotal pain.
And all that was ordered were the scrotal ultrasound.
So here's the scrotal ultrasound.
Now the testicle or both testicles were normal, but this is what she saw, multiple structures on the black and white picture showing extensive flow.
And if we put a spectral doppler, which would always do to determine what kind of flow we're talking about, this is venous flow.
So these are bilateral large varicoceles, and by definition, varicocele is, there is a dilation of a vein that's more than 2.7 millimeter, which is a subclinical to three millimeters, which is a clinical varicocele.
Now this were bilateral, this is the right side and the left side and the sonographer without before showing us the case.
So that's really all the credit goes to her.
Said, okay, well I've never seen this very solid, very good seal.
Seem very big. And we always teach the sonographer is there is a very good seal and the bilateral, the right sided, the bilateral, just go and look around in the abdomen, look at the renal vein.
So while she was looking at the renal vein, this is what she saw.
Okay, so this is a sagittal clip through the left flank where you can see here the left kidney coming in view and there is this large, what she thought was a large mass.
So of course then she called us and we started looking, and this is just a still image of the same where you see the lower pole of the left kidney and this large mass, which is echogenic.
And then in the right lower quadrant in the mid abdomen, we saw this very large, we couldn't see any bowel gas.
And this is this large, very high echogenic mass.
Alright? So we think the patient has a large mass in the abdomen, and because it's very echogenic, you're going to think about fat.
So of course the patient immediately had a CT scan.
And you can see on the still images here, axial images and the coronal movie that I show you, that the patient in fact had a very large fatty mass in the abdomen with some, of course, some solid components, some septations, some nodules.
Here's another more solid component enhancing component of this mass.
And this is of course consistent with a retroperitoneal sarcoma.
And even when they went back in this man, which was pretty muscular, this was very difficult to palpate what appears to be a very large abdominal mass, probably because a lot of the mass is fatty and therefore not that hard.
So this is how this retroperitoneal sarcoma in this patient presented.

So what are varicoceles are basically dilated tortuous vein form venous plexus.
And there are of course idiopathic varicocele, which have left-sided predominance, obviously diagnosed in males.
But it can be a cause of either pain, usually dull pain or possibly infertility in men.
And then there's secondary varicocele.
We should always keep that in mind.
The result from increased pressure on the spermatic vein, and there are several perhaps some mechanism sometimes may be a nut cracker syndrome with compression of the left renal vein.
Also if you have a unilateral right-sided varicocele, you also have to consider the possibility that this could be a secondary varicocele, or if you have a newly discovered varicocele in the male older than 40, then also think about the possibility of and underlying etiology causing the varicocele.
And in all these cases, you should look for an abdominal mass or a clot in the renal vein or the IVC, and we've all read about renal cell carcinoma, renal cell carcinoma presenting with a varicocele because of a clot in the renal vein or the IVC.

Case: Scar Endometriosis

Okay? So my next case is that of a 33-year-old woman who had a painful, palpable abdominal mass and the clinician requested a CT scan.
Now, in this patient population, my first choice, if somebody was asking me what I recommend would not be a ct, it should be an ultrasound.
But anyway, the patient on the had a CT scan that was ordered.
And so I'm showing you the axial images through the lower pelvis.
This is the area of the pain presumably.
And so this is how we read it.
And then just think about a little bit about what you think it could be, fluid collection with worm enhancement surrounding inflammation and induration of the right rectus muscle and no specific diagnosis was offered.
So really that's the first problem, right?
Because as radiologists, we should, or sonographers or radiologists, we should not just describe a finding.
We should either think what we think it is, offer a differential diagnosis or at the very least offer if we don't know, be honest and say, I'm not sure, but don't just describe things and don't give a specific diagnosis.

So in this patient, after she had a CT scan, I read her clinic notes and it said, abdominal pain and tenderness around mans CT non-contributory.
Now she a few months later came for the ultrasound.
At that time I hadn't read this clinic note, but this is what we saw on the ultrasound.
So this is a transabdominal ultrasound and this is the fundus, the area of the fundus uterus.
And then this is the area of the palpable abnormality.
Of course, the big advantage of ultrasound, in addition to the lack of radiation is that it's an interactive study.
We went in the room, made sure that we were scanning exactly where the patient hurt.
That's very important.
And then if you know what you're, you know, what you ask, you ask a few questions, right?
So the first question you ask, well, we didn't really need to ask because you can see nicely on the sagittal transvaginal ultrasound of uterus that there is a scar here.
So this is C-section scar.
So we already knew the answer when we asked the patient, do you have a, have you had a C-section?
And then when we asked the patient, well, when does it hurt?
Does it hurt more in some part of the month more than others, she did give a diagnosis was more like cyclic, and she also had focal tenderness.
So now a diagnosis becomes much easier, right?
So we said, so what do you, what could it be?
Well, we really strongly suggested in the ultrasound report, this is very likely to be abdominal wall endometriosis.
Classic history after cesarean section.
The patient also had an mr.
I'm not exactly sure why, but she did.
And the sagittal T two MR here shows a blood fluid level within the collection, which confirms of course that this diagnosis of endometrial implant in the C-section scar and extending into the abdominal wall.

So scar endometriosis, and we are going to see more of them because we see more and more patient with a cesarean section.
So it's most common F of C-section.
And basically what happens is that there is dissemination of endometrial cells at the time of surgery.
It's often a lesion that infiltrates deep into the rectus abdominal muscle, and it may not be associated with pelvic endometriosis, not, some many of these patients do not actually have endometriosis in the pelvis.
A preoperative diagnosis, if you look at the literature, is only made in 20 to 50% of the women, probably because we don't really think about it.
And on ultrasound, it can actually look pretty ugly if you don't think about it.
Solid hypoechoic, heterogeneous, it couldn't have an irregular or spiculated margin because of the infiltrated nature of the lesion.
And they may have internal vascularity.

So this is another example of a patient who had a white low cord palpable mass.
You see this hypoechoic mass, which is lobulated again, this was a relative young woman, and she had a c-section scar.
Now she ended up having surgical removal as an outside hospital, probably unnecessary.
What we do, if we're not sure of the diagnosis or if the patient is particularly anxious, you can do a core biopsy of the lesion to prove that this is endometriosis stop.

So what is a differential diagnosis or scar endometriosis where desmoid tumor, a suture granuloma hematoma, but of course, metastatic disease always is the back of our mind.
And classic would be ovarian cancer.
Pancreatic cancer. And again, in patients where we're not sure about the diagnosis.
So the patient's particularly anxious, you can do fine needle aspiration, but more importantly, core biopsies that will prove the diagnosis.

So this is a, of course, a mimic another patient with an lobulated hypoechoic mass into abdominal wall.
But this patient had a history of colon cancer, and this of course was a metastatic colon cancer into the abdominal wall.

So the teaching points for this case is it's very important to elicit specific history.
And with ultrasound we have a big advantage because we can go in the room and ask the patient, we should always try to offer a specific diagnosis or a differential diagnosis.

Case: Lymphoma of the Spermatic Cord

Okay, so my next case is that of an 87-year-old man with who had a palpable left scrotal mass.
He was previously treated for epididymitis, and so he had a CT and an ultrasound requested and they were performed.
So the CT was performed first.
So you can see here on the clip as well as the still picture that there is a large soft tissue mass in the region of the inguinal region extending all the way to this scrotum.
And there's also inguinal lymphadenopathy, okay?
There was no upper abdominal lymphadenopathy.
And so it was read as I think it's very appropriately suspicious for sarcoma.
So then we did the ultrasound, and you can see here the testicle.
The patient had big hydrocele, but the testicle itself is normal.
There is a very large mass in the region of the vas deferens, hypervascular.
And it was extending above the head of the left epididymis extending towards the left inguinal canal.
And I just give you an image with a curvilinear.
So we again, thought that this was going to be a sarcoma, but of course, the patient had an ultrasound-guided fine needle aspiration and core biopsies.
And the final diagnosis was large B-cell lymphoma.

So let's talk about lymphoma of the lower GU tract for a minute.
Primary lymphoma of the spermatic cord, which this probably was, is extremely uncommon.
It's a very rare lymphoma B-cell usually typically present as our patient in older man with palpable mass.
And on imaging, and this is a nice example I just showed, is infiltrative mass surrounding the spermatic vessels.
Now, testicular lymphomas are more common.
It's actually the most common testicular neoplasm in men over 60 and certainly over 70 years of age.
Typically, they'll present with painless enlargement or palpable testicular mass.
The masses can be uni or bilateral, or it can present with diffuse testicular enlargement.
They're usually hypervascular on color doppler.
And what we should do is look for disseminated disease, particularly look for pelvic and para aortic lymphadenopathy, and it does not have a very good prognosis.

So this is a classic example of a testicle lymphoma.
This patient's younger than the typical age group, but he has HIV AIDS.
And you can see here this is a normal right testicle here, on sagittal as well as transverse.
And you can see that the left testicle is enlarged with increased flow.
We don't really see any focal mass.
And really you have to be careful and think about this diagnosis because the ultrasound appearance can really mimic, or which I think it does in this particular patient.
And another patient. And that's what we said, appearance suggestive of epididymitis recommend follow up, which unfortunately how it was read initially.
And the patient had radical orchiectomy because he wasn't getting better, and had diffuse a large B-cell lymphoma.

Okay? So in terms of tumors of the spermatic cord, usually they're, first of all, they're very uncommon.
They can be mesenchymal tumor, they can be lipoma or liposarcoma.
As you can see here, this is a very amorphous hypoechoic tumor.
Very little flow. Here's a CT scan.
Really some fat, but some of course some solid components.
So it's a liposarcoma.
You can also have like a fibrosarcoma, malignant histiocytoma and lymphoma as I showed you the first case.

So what are the teaching points in this case?
First of all, it's very useful again, in this patient, even though the initial request may be to scan the scrotum to use large field of view or curvilinear transducers who have to have a good idea of the size of the tumor.
Always remember that lymphoma is the great mimicker.
Usually they present with painless enlargement.
And if you think about it, mention cause you look for abdominal lymphadenopathy and percutaneous biopsies, of course is a great way to make the diagnosis of lymphoma.
Remember that you have to send flow cytometry as well.

Non-Traditional Applications of Endovaginal Ultrasound

So my next case is that of a 26-year-old woman with right lower quadrant pain and nausea, and their clinical impression was pelvic inflammatory disease versus acute appendicitis.
So a pelvic ultrasound was requested.
So I'm giving you several images from the endovaginal ultrasound, and you can see here that her right ovary is normal.
She has a little bit of fluid and she has this tubular structure here, which is hyperemic.
So the question is, what is it?
Is this pelvic inflammatory disease or is that something else?
And if we look at the tubular structure very carefully, then you know that the at the inside here, the mucosa submucosal interface is very echogenic, right?
And so, and this is a blind ending loop.
So basically the what this is, is the appendix, it was in the pelvis, and that's why we could see it nicely on the vaginal ultrasound.
Notice also that the fat around it is echogenic, which is inflamed fat.
That's the ultrasound equivalent of mesenteric stranding or dirty fat.
Okay? Very useful sign to confirm the presence of inflammation.
And I'm just showing you the difference between bowel here, the in this case, the appendix and a fallopian tube, what the echogenic area would be on the outside and not the inside.
What this is, is the mucosa submucosal interface here, and this is what a pyosalpinx looks like.
So thickened echogenic outer border with internal echoes inside, because this is a pyosalpinx, and if you look at it on the transverse cuts, you see this thickened wall.

So this is a case of pyosalpinx in a different patient.
This is our patient who had acute appendicitis.
And so I want to take the opportunity with this case to discuss some of the non-traditional or non GYN application of endovaginal ultrasound and first talk about GI application.

GI Applications

So this is what a normal loop of bowel potentially can look like.
The wall is not thickened here.
If you put color, there'll be no hyperemia.
The fat is not really standing out that much.
And it's important to think about it because the some of the GI symptoms may actually mimic GYN pathology.
And so think about, as I said, the character gut signature.
I talked about the echogenic inflamed fat that can have you almost have a mass effect.
And the things that typically we can see with endovaginal ultrasound in GI applications, acute appendicitis, diverticulitis and diverticular abscess and Crohn's disease and its complications.

So this is an example, this is a old case that this patient had what was thought was pelvic inflammatory disease.
But if you look at it again, the wall of the structure is very thick and the inside is very echogenic.
So that's the opposite of what we you would have expect in a thickened fallopian tube.
And what is this? This is a very thick sigmoid colon.
The patient was focally tender and she, so which suggested the diagnosis of diverticulitis and the ct, again confirms the presence of thickened sigmoid with hypoechoic, with thickened muscular layer that you can see here, the hypoechoic muscularis propria.

If you have a diverticular or for that matter, an appendiceal or abscess, what you'll see, you won't recognize the bowel as well.
You'll see an amorphous mass.
As you can see here, this echogenic focus may represent air.
So anytime you see air in a pelvic abscess, think about the possibility that's arising from the GI tract because usually one of the male GYN origin tuboovarian abscess usually do not have air.
And so based on this, we were worried about the pelvic abscess from a GI origin.
So the patient went to a CT scan, and you can see here that she has multiple diverticula and she had a big abscess posterior to the uterus right here in the pelvis.

Urological Applications

There are some urological applications as well, because again, distal ureteral stones can mimic GYN pathology.
And with endovaginal ultrasound, you can really see the distal ureter.
And it's easier to see in the sagittal plane.
So here's the bladder and here's the ureter coming in.
You can see the wall is a little thick and there is this echogenic structure here.
And if we put color, we don't really see a good jet, we just see kind of a little bit of urine dribbling by.
Okay? And so this is a useful application to think about, especially if the patient is pregnant and you the majority of the stones that obstruct or in the distal ureter.
So it's a good application, especially in pregnant women.
With endovaginal ultrasound, we can see the ureter.
We can also see the bladder.
And if you really want to look at the urethra, you can see too, just remember to very slowly withdraw the EV probe in the vagina to be able to see the urethra.

So this is a different patient who had a lower abdominal pain.
So she was 25 years old and she did a the right, a pelvic ultrasound was requested.
And on the endovaginal ultrasound, the uterus and ovaries were normal, but we saw this kind of duct structure without flow when we put the color.
So we said, okay, what lives there?
Well, it could be a tube but didn't quite look like a tube, or it could be the ureter, right?
So she had a transabdominal portion of the study.
You can see the very dilated distal left ureter.
You can see it nicely on the endovaginal portion of the study here.
And so if you have a very dilated ureter and a young woman, you better look at the kidney, which is what we did here.
So here's the left kidney, and you see this D structure going all the way to the upper pole, and there is a hydronephrotic upper pole.
The lower pole looks more normal in this left kidney.
And so if you look at the CT here, you can see that there is a hydronephrotic upper pole with a normal lower pole of the left kidney.
Here's a dilated ureter, here's a dilated ureter in the pelvis.
Okay, so a diagnosis with duplicated left collecting system with hydronephrosis of the left upper moiety, an ectopic insertion of the left ureter.

And then another patient who had a bladder abnormality diagnosed with endovaginal ultrasound.
This was a completely incidental finding.
We were doing a pelvic ultrasound for suspected abortion, and she has this well-defined mass, which has a fibrovascular core.
Okay? So obviously you are worried about the bladder cancer be very unusual in her 30-year-old.
But definitely the patient needs cystoscopy and she had cystoscopy and resection of this tumor would turn out to be a benign fibroepithelial polyp.

The other thing that I think endovaginal ultrasound is useful for, and if you have a patient who has cancer, particular ovarian cancer or marked ascites and you're doing an endovaginal ultrasound, don't just look at the ascites, okay?
You could see this patient has complex fluid, okay?
So you're worried about malignancy, but if you look at the edge of the fluid, you can see here that there's all these soft tissue masses here in the fluid.
And this is carcinomatosis. Okay?
So EV is very good in showing tumor implants on the pelvic sidewall.

And finally, there are also veins living in the pelvis.
And you will sometimes pick up incidental clot.
And this is a patient who had an ultrasound for an adrenal mass in on CT.
And I do not quite remember what the adrenal mass was, but what I remember was that the in the right external iliac vein, you see this clot here, okay?
It is not completely occlusive, but there's a clot here.
And the patient did have a past history of pulmonary emboli.

So in summary, of course we use endovaginal ultrasound to look at the GYN organs, but remember that it can be a problem solving tool outside the GYN, especially if you're looking for distal ureter stones in a pregnant woman.
Or sometimes you will just see incidental findings and you need to try to figure out what they are.
And so just remember to look around, avoid tunnel vision and be creative.
And this is a very good article if you want to look at other examples of what you know, extra GYN abnormalities you can see with endovaginal ultrasound.

Case: Pediatric Ovarian Neoplasm

Okay? My next case is that of a 14-year-old girl who had presented with abdominal distension and discomfort seen in the emergency department.
She was sexually active and she had a HCG that was positive but very low of 89.
So we did a pelvic ultrasound.
And on the pelvic ultrasound you can see here that the uterus is rather small here, but there there is a very large solid pelvic mass, 11 centimeter mass.
And again, on the endovaginal, we did an endovaginal ultrasound, just to confirm there was no retained products, but we see a very large solid appearing mass with increased vascularity.
And so the way we read it, and I think it's not an unreasonable thing, it's to the pelvic solid pelvic ovarian neoplasm.
Now, in a 14-year-old patient, remember this patient is 14, ovarian neoplasm are rather unusual, or perhaps a just tumor.
So her repeated HCG was hundred, and how D-A-G-F-P and tumor markers were done and these other values here.
And so in a young patient, what do we think about?
Well, the thing, it doesn't look like a regular cystic teratoma.
And usually you see those a little bit older women, young women, but not children basically.
And so of course she needs surgery for this ovarian mass and it's surgery.
This was a dysgerminoma of the left ovary.

And so when we talk about pediatric ovarian neoplasm, we need to think about germ cell tumors, but they usually arise from the primitive cells of the embryo gonad.
And they're most common.
So dysgerminoma, not the cystic teratoma that you're going to see later in life, about 30% are malignant.
You can also see sex cord stromal tumors, which represent 10 to 20% of pediatric ovarian tumors.
You can have juvenile granulosa cell tumors as part of this, and they can present with isosexual puberty.
And finally, less commonly you can have epithelial neoplasm, which are usually benign or borderline, and then lymphoma and leukemia.

So if in terms of germ cell tumors in children, mature teratomas represent 50% of all pediatric ovarian neoplasm.
But again, they're not that common in this age group.
But you always have to think about immature teratoma, which are, as I said, younger age group than the mature teratoma.
They will present large solid or solid and cystic ovarian masses.
They may have calcifications and fat and they can have elevated AFP.
And the dysgerminoma, which are malignant, which are similar to testicular seminoma in the male, will typically present a solid large echogenic lobulated mass.
And they can have elevated LDH and that they're outpatient.
They can also have elevated HCG.

Okay, So this is a 11-year-old girl who presented with enlarging abdominal girth.
And so you see that she has ascites and she has this in a very large ugly looking mass, actually with some, maybe some calcification, some increased vascularity.
Here's a CT scan again showing the mass you maybe some small amount of fat here, ascites.
And this at surgery was an immature teratoma with yolk sac tumor within it.

Case: Burned-Out Germ Cell Tumor

Okay, And finally this is a 43-year-old man who had a CT for abdominal pain.
And this is what we see.
So he has a retroperitoneal nodal mass, what looks like a nodal mass.
It's encasing the aorta causing hydronephrosis.
It's a very large mass. So what should we think about?
Well, of course we're gonna think about the possible lymphoma, but remember he's a 43-year-old man.
So another thing to always think about is the possibility of a germ cell tumor in the testicle.
So he did have a scrotal ultrasound as part of his workup.
And basically the ultrasound is almost normal except for this other area, little area which measures seven by four millimeters.
That's the only thing we could find.
And one thing you think about in this case is think about the possibility of burned out germ cell tumor.
So we did an ultrasound guided biopsy, the retroperitoneal mass, which confirmed the diagnosis of seminoma in that area.
And at surgery there was also a burned out germ cell tumor in the testicle.

So this occult testicular germ cell tumor present with mediastinal retroperitoneal masses, or occasionally supraclavicular masses.
Usually there is no palpable abnormality of the testis and the ultrasound may be of the testicle, may be normal or show a small hypoechoic mass or area which may have calcification and histology that this patient, they have a scar consistent with burned down germ cell tumor with no viable tumor.
And it's possible that the regression may be caused by high metabolic rate within the tumor, causing some ischemic changes us.

So I thank you very much for your attention.