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Peritoneal inclusion cyst in an 18-year-old woman with left iliac fossa pain. (a) Transabdominal US image shows a hypoechoeic cystic locule conforming to the peritoneum. The left ovary (arrowhead) and broad ligament (arrows) are separate from, but entrapped within, the cyst. (b) Sagittal T2-weighted MR image shows the high-signal-intensity fluid-filled peritoneal inclusion cyst conforming to the peritoneum. The right ovary is entrapped within the cystic locule (arrow). (c) Coronal T2-weighted MR image shows that both ovaries are entrapped within the peritoneal inclusion cyst (arrows).
Source publication
Cystic disease in the female pelvis is common. The majority of cystic pelvic masses originate in the ovary, and they can range from simple, functional cysts to malignant ovarian tumors. Mimics of ovarian cystic masses include peritoneal inclusion cyst, paraovarian cyst, mucocele of the appendix, obstructed fallopian tube (eg, hydrosalpinx, pyosalpi...
Contexts in source publication
Context 1
... inclusion cysts occur almost exclusively in premenopausal women with active ovaries, pelvic adhesions, and impaired absorp- tion of peritoneal fluid, which leads to formation of fluid-filled cysts that conform to the shape of the peritoneal cavity, and they may recur (1). At imaging, the ovaries are entrapped by, but clearly separate from, the cystic locules (Figs 3, 4) (1). ...
Context 2
... by only a thin stalk, from which it receives blood, or if it is parasitized, meaning it receives blood from nearby structures. An exophytic or pedunculated leiomyoma also may mimic a cystic adnexal mass if cystic degeneration is present (Fig 13). Four percent of leiomyomas undergo cystic degeneration, with extensive edema form- ing cystic, fluid-filled spaces. ...
Context 3
... features of pelvic abscess vary, with thick or thin walls, simple or complex fluid collections, adjacent inflammatory fat strand- ing, free fluid, and inflammation of surrounding organs seen at all modalities (Figs 22, 23). Air from gas-forming organisms or fistulization with adjacent bowel may be seen. ...
Context 4
... from gas-forming organisms or fistulization with adjacent bowel may be seen. It may be difficult to Figure 23. Pelvic abscess secondary to pelvic inflammatory disease in a 36-year-old woman with fever and lower abdominal pain. ...
Context 5
... inclusion cysts occur almost exclusively in premenopausal women with active ovaries, pelvic adhesions, and impaired absorption of peritoneal fluid, which leads to formation of fluid-filled cysts that conform to the shape of the peritoneal cavity, and they may recur (1). At imaging, the ovaries are entrapped by, but clearly separate from, the cystic locules (Figs 3, 4) (1). ...
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Endometrial pathology, including hyperplastic processes in the structure of reproductive disorders, occupies one of the leading places along with inflammatory diseases of the pelvic organs, contributing to infertility in 80% of cases and irregular menstrual cycle in 40-43%. This study aims to optimize the diagnostic algorithm in patients with endom...
Citations
... Pertenece al grupo de quistes del desarrollo del intestino terminal, con origen en vestigios de tejido embrionario, y es infrecuente 1,2 . Suele ser un hallazgo casual en mujeres de mediana edad y puede dar síntomas si produce efecto de masa 2,3 . ...
... Consiste en una proliferación reactiva mesotelial no maligna de las células peritoneales por una lesión previa 1,6 . Dicha lesión puede ser ocasionada por endometriosis, enfermedad inflamatoria pélvica, trauma o cirugía abdominal previa. ...
... Despite not aligning with the pathogenic theories of endometriosis dissemination, tailgut cysts may routinely be misdiagnosed as cystic endometriosis lesions. Indeed, while deep extra or retroperitoneal endometriosis mainly consist of an extension from DIE, tailgut cysts appear on MRI as isolated thin-walled uni-or multilocular cystic masses [69], with low signal intensity on T1-WI, although they can be T1-hyperintense depending on their mucoid content, and exhibit variable signal intensity on T2-WI ranging from T2-hyperintense to T2-hypointense ( Fig. 9) [70]. Contrast-enhanced T1-WI can reveal thick and regular septa and vegetations, which are indicative of possible malignant transformation to adenocarcinoma [71]. ...
Endometriosis is a chronic and disabling gynecological disease that affects women of reproductive age. Magnetic resonance imaging (MRI) is considered the cornerstone radiological technique for both the diagnosis and management of endometriosis. While MRI offers higher sensitivity compared to ultrasonography, it is prone to false-positive results, leading to decreased specificity. False-positive findings can arise from various T1-hyperintense conditions on fat-suppressed T1-weighted images, resembling endometriotic cystic lesions in different anatomical compartments. These conditions include hemorrhage, hyperproteic content, MRI artifacts, feces, or melanin. Such false positives can have significant implications for patient care, ranging from incorrect diagnoses to unnecessary medical or surgical interventions and subsequent follow-up. To address these challenges, this educational review aims to provide radiologists with comprehensive knowledge about MRI criteria, potential pitfalls, and differential diagnoses, ultimately reducing false-positive results related to T1-hyperintense abnormalities.
Critical relevance statement
MRI has a 10% false-positive rate, leading to misdiagnosis. T1-hyperintense lesions, observed in the three phenotypes of pelvic endometriosis, can also be seen in various other causes, mainly caused by hemorrhages, high protein concentrations, and artifacts.
Key points
• MRI in endometriosis has a 10% false-positive rate, leading to potential misdiagnosis.
• Pelvic endometriosis lesions can exhibit T1-hyperintensity across their three phenotypes.
• A definitive diagnosis of a T1-hyperintense endometriotic lesion is crucial for patient management.
• Hemorrhages, high protein concentrations, lipids, and artifacts are the main sources of T1-hyperintense mimickers.
Graphical Abstract
... Kishimoto et al. reported that MRI findings of paraovarian cysts are less specific especially when the cysts are abutting, compressing, or displacing the ovary [26]. Paraovarian cysts that are complicated by torsion or hemorrhage may demonstrate high T1 signal and thick walls [27]. In our series, the addition of contrast did not compel either reader to change their pre-contrast diagnosis for any of the three patients with surgically confirmed torsed paraovarian lesions. ...
Purpose
Ultrasound is the first-line imaging modality to evaluate adnexa in girls with clinical suspicion of torsion. Patients with equivocal ultrasound findings can undergo MRI for better delineation of adnexal pathology. Here, we assess the utility of intravenous contrast in MRI evaluation of adnexal torsion in children.
Methods
Two pediatric radiologists (R1, R2) retrospectively reviewed 198 pelvic MRI exams in 172 girls (median age 15 years). Each MRI was reviewed twice. The first review included pre-contrast images only. A second review, at least 1 month later, included both pre- and post-contrast images. Readers concluded if findings were suspicious for torsion or not. Readers’ findings were compared to each other’s and to surgical and MRI reports and clinical course.
Results
198 MRI exams yielded 354 evaluable ovaries. Surgical and pathological reports were available for 47 patients. 11 patients had adnexal torsion. Both readers accurately diagnosed acutely torsed ovaries during pre- and post-contrast reviews (n = 4). However, readers disagreed on torsed paraovarian cysts (n = 4) and chronically/intermittently torsed ovaries (n = 3). In 21 non-torsed ovaries that had lesions, one or both readers concluded that there were pre-contrast features of torsion. In this set with ovarian lesions, contrast helped readers to correctly conclude no torsion (R1 = 8, R2 = 6) more commonly than to incorrectly conclude torsion (1 each), improving post-contrast specificity for each reader.
Conclusions
Post-contrast sequences did not provide additional benefit in evaluating acutely torsed ovaries but helped in excluding torsion in patients with adnexal lesions. Therefore, contrast administration should be individualized, potentially reserved only for those with abnormal ultrasound or pre-contrast images.
Graphical abstract
... 4 PIC are nearly exclusively seen in patients with a history of abdominal or pelvic surgery, usually between 6 months up to 20 years after the surgery. 2 Literature mentions PIC after laparoscopic surgery is rare compared to abdominal hysterectomy and for the same reason, laparoscopic resection is preferred over laparotomy when considering surgical resection of PIC. 7 PIC can also be seen with chronic inflammatory processes including endometriosis, inflammatory bowel disease, and pelvic inflammatory disease. 4,7,8 We present a patient in the reproductive age group with an extensive history of abdominal surgeries, myriad of typical and atypical clinical symptoms, and negative tumor markers. ...
... The white paper of the ACR incidental findings committee mentions no further evaluation is required in an incidental PIC. 10 The PIC has an irregular shape due to pseudocyst lacking wall and conforms to shape from the adjacent structures. 5,8 Ultrasound demonstrates anechoic cysts with thin septations <5 mm and in case of hemorrhagic or proteinaceous contents, they can appear as echogenic cysts with septations. The ovary entrapped in the cyst between adhesions can have a "spider in a web" appearance however the ovaries are not usually clearly delineated on ultrasound like in an MRI. ...
... The ovary entrapped in the cyst between adhesions can have a "spider in a web" appearance however the ovaries are not usually clearly delineated on ultrasound like in an MRI. 2,3,5,8 Doppler examination will demonstrate a low-pressure flow pattern with resistive index (RI) of 0.50-0.60 in the septal wall. 2 CT similarly depicts fluid density mass with irregular borders with attenuation varying depending on the fluid contents. 3,5,8 On MRI, the lesion with serous content demonstrates T1 hypointensity and T2 hyperintensity; and the one with hemorrhagic content demonstrates T1 hyperintensity with T2 intermediate or hypointensity. ...
Peritoneal inclusion cysts (PIC) occur most frequently when abdominal adhesions attach to an ovary. These adhesions are commonly seen in patients with a history of abdominal surgery. Physiologic fluid following ovulation that would normally be absorbed by the peritoneum gets entrapped within these adhesions. Women most frequently complain of back pain or pelvic pain when peritoneal inclusion cysts are present. We present a patient with prior surgical history who presented with suprapubic pain and was found to have a complex cyst on imaging. Gynecologic oncology was consulted due to its complex imaging appearance and large size and was ultimately resected despite negative tumor markers. We present our case with pathologic correlation of imaging findings to emphasize this benign entity with no malignant potential. A confident imaging diagnosis in correlation with laboratory markers can help prevent aggressive surgical management.
... A paraovarian cyst is made up of the congenital remnants of the embryonic Wolffian duct, originating from the mesosalpinx at the upper border of the broad ligament. These cysts represent 10-20% of all adnexal masses [29]. Paraovarian cysts are often simple and rarely complicated by hemorrhage, debris torsion, and malignant transformation. ...
... Identifying the location of a cyst as ovarian or paraovarian can be challenging; gentle pressure with a transvaginal probe can be applied to separate the paraovarian cyst from the adjacent ovary. Additionally, paraovarian cysts lack the crescentic ovarian parenchyma at the periphery "claw sign" that can be seen with eccentric ovarian cysts [29,30]. MRI help identify the paraovarian cysts separate from the ovary and the uncomplicated paraovarian cysts usually show hypointense T1 signals and hyperintense T2 signals, similar to functional cysts ( Figure 8) [1]. ...
... fying the location of a cyst as ovarian or paraovarian can be challenging; gentle pressure with a transvaginal probe can be applied to separate the paraovarian cyst from the adjacent ovary. Additionally, paraovarian cysts lack the crescentic ovarian parenchyma at the periphery "claw sign" that can be seen with eccentric ovarian cysts [29,30]. MRI help identify the paraovarian cysts separate from the ovary and the uncomplicated paraovarian cysts usually show hypointense T1 signals and hyperintense T2 signals, similar to functional cysts (Figure 8) [1]. ...
The complex anatomy and similarity of imaging features of various pathologies in the pelvis can make accurate radiology interpretation difficult. While prompt recognition of ovarian cancer remains essential, awareness of processes that mimic ovarian tumors can avoid potential misdiagnosis and unnecessary surgery. This article details the female pelvic anatomy and highlights relevant imaging features that mimic extra-ovarian tumors, to help the radiologists accurately build a differential diagnosis of a lesion occupying the adnexa.
... Paraovarian cysts are also known as paratubal cysts since they arise as simple cysts near the ovary or the fallopian tube [1]. They have been reported in women of all ages, and their incidence is estimated to be around 10-20% of adnexal masses [6]. Rarely, tumors such as borderline papillary tumors may arise in a paraovarian cyst. ...
... Anatomically, a paraovarian cyst is located within the peritoneal space. The findings on ultrasound imaging are usually specific as in the case of our patient [6]: paraovarian cysts appear as a simple unilocular cyst separate from a normal ipsilateral ovary [7]. However, sonographic diagnosis is not always feasible, as preoperative diagnosis of paraovarian cysts was possible in only 6.6% of cases in one study by Liu et al. (2019) [8], and in up to 44% of cases in an older study by Jung Sik Kim et al. (1995) [2]. ...
... In another Chinese study, 4 out of 117 cases of paraovarian cysts were considered as lowgrade malignancies (3.4%) [10]. According to Moyle et al. (2010), neoplasms arising from paraovarian cysts can be benign, or malignant such as papillary serous cystadenoma, serous cystadenocarcinoma, endometrioid cystadenocarcinoma, or mucinous cystadenocarcinoma [6]. ...
Background: Paraovarian cysts are benign cysts that develop near the ovaries and fallopian tubes in the pelvic region. They can cause mass effects requiring excision. In rare cases, tumors may develop inside these cysts. These tumors may be benign, malignant, or borderline. Case Report: A 26-year-old lady presented for excision of a paraovarian cyst. Pre-operative imaging showed the presence of few undulating folds at the periphery of the cyst. The patient underwent laparoscopic pelvic cystectomy without intra-operative drainage. Pathological examination of the specimen revealed a borderline serous papillary tumor protruding from the cyst wall. Conclusion: The occurrence of a borderline tumor, also known as a tumor of low malignant potential, in a pre-existing paraovarian cyst is very rare and has only been reported few times in the literature. A thorough review of these cases showed that the most common imaging finding that raises suspicion for a borderline tumor within a paraovarian cyst is the presence of small intracystic projections within the unilocular adnexal cyst. However, since evaluating the presence of an intracystic tumor is not always possible, performing a fertility-preserving laparoscopic cystectomy without cyst content spillage, is recommended. If properly excised, the prognosis of this tumor is good, and recurrence is rare.
... with intense FDG uptake. 141,142 Appendicitis and diverticulitis can be difficult to distinguish from PID in case of adnexal involvement and abscess formation. 132 Diverticulosis has a high a high prevalence in the general population and the presence of diverticula in involved segments is indicative of diverticulitis 143 (Fig. 12). ...
The role of hybrid imaging with 2-[18F] flourodeoxyglucose (FDG) positron emission tomography and computed tomography (PET/CT) is continuously evolving and now considered standard practice in evaluation of disease stage, treatment response, recurrent disease and follow-up for numerous primary malignancies. In gynecological malignancies FDG PET/CT plays an important role, not only in the assessment of disease in the pre-and post-therapy setting, but also in radiation therapy (RT) planning by defining the metabolically active gross tumor volume (GTV. The glucose analogue radiotracer, FDG, is by far the most utilized radiotracer in PET/CT and is typically seen with high uptake in malignant cells. The radiotracer FDG has a high sensitivity but low specificity for malignancy, as benign processes with an inflammatory response for example infection, are also FDG-avid. In the evaluation of the female pelvic region an awareness of potential confounding factors in the interpretation of FDG is essential as variations of FDG uptake occur in accordance with the menstrual cycle and the menopausal state. Incidental imaging findings in the female genital can pose differential diagnostic challenges as false-positive and false-negative findings in benign and malignant processes are not uncommon. Gynecological malignancies continue to pose major public health problems with cervical cancer as the fourth most common cancer in women ranking after breast cancer, colorectal cancer and lung cancer. Familiarity with frequently encountered benign and malignant variants and pitfalls in FDG PET/CT in the female pelvic region can aid the reader in differential diagnostic considerations.
... Lymphocele fluid creatinine, urea nitrogen, and electrolyte concentration levels are similar to the concentrations of those parameters in serum [18]. ...
‘-Celes’ is an ancient Greek language suffix that means ‘tumor,’ ‘hernia,’ ‘swelling,’ or ‘cavity.’ There are many ‘-celes’ in the abdomen and pelvis that may be encountered during routine imaging interpretation, including santorinicele, choledochocele, ureterocele, lymphocele, mucocele, rectocele, cystocele, peritoneocele, varicocele, spermatocele, hydrocele, hematocele, pyocele and syringocele. Most ‘-celes’ are detected incidentally at imaging for other clinical indications, but some deserve more attention due to a range of clinical symptoms or functional disorder that can adversely affect patient quality of life. The objective of this article was to address all of the ‘-celes’ that a general radiologist and abdominal radiologist should know and be able to recognize. Imaging characteristics, diagnostic clues, and pitfalls have been provided to improve diagnostic accuracy and patient outcomes.
... For example, ultrasound is helpful in evaluation of ovarian torsion, but more limited in diagnosing conditions such as endometriosis [43][44][45][46][47] . Nono-varian pathologies or atypical ovarian conditions can mimic normal ovarian anatomy or benign ovarian processes and are a potential cause of perceptual error for clinicians and radiologists [48] . The intrinsic poor contrast and limited field of view of transvaginal ultrasound when compared to CT and MRI further subject ultrasound to adnexal evaluation pitfalls [49] . ...
Ultrasound is a first line imaging modality for the evaluation of female pelvic pain. Pelvic pain constitutes one of the most common reasons for presentation to the emergency department with increasing use of point of care ultrasound. Infrequently, point of care or formal ultrasound evaluation may lead to misdiagnosis of extraovarian disease. This can have serious consequences, especially if an extraovarian malignancy is mistaken for a normal ovary or an ovary with a benign process. We present a case of a 41-year-old female who presented to the emergency department for a chief complaint of pelvic pain and vaginal bleeding. Transvaginal ultrasound demonstrated a left adnexal mass, later characterized as a sigmoid colon cancer on MRI and pathology, simulating ovarian echotexture with peripheral hypoechoic components resembling follicles. This article will review the literature of various cases of extraovarian pathology misidentified as ovarian processes and highlight the importance of considering these extraovarian mimickers to prevent potential morbidity and mortality of a missed diagnosis.
... They occur almost exclusively in premenopausal women and at imaging the ovaries are clearly separated from these cystic formations. 27,28 Functional ovarian cysts are the most common finding in women of reproductive age. Follicles are up to 20 mm as the dominant one could be 25 mm. ...
Background
To assess different types of adnexal masses as identified by 3T MRI and to discuss the added value of diffusion techniques compared with conventional sequences.
Patients and methods
174 women age between 13 and 87 underwent an MRI examination of the pelvis for a period of three years. Patients were examined in two radiology departments – 135 of them on 3 Tesla MRI Siemens Verio and 39 on 3 Tesla MRI Philips Ingenia. At least one adnexal mass was diagnosed in 98 patients and they are subject to this study. Some of them were reviewed retrospectively. Data from patients’ history, physical examination and laboratory tests were reviewed as well.
Results
124 ovarian masses in 98 females’ group of average age 47.2 years were detected. Following the MRI criteria, 59.2% of the cases were considered benign, 30.6% malignant and 10.2% borderline. Out of all masses 58.1% were classified as cystic, 12.9% as solid and 29% as mixed. Оf histologically proven tumors 74.4% were benign and 25.6% were malignant. All of the malignant tumors had restricted diffusion. 64 out of all patients underwent contrast enhancement. (34 there were a subject of contraindications). 39 (61%) of the masses showed contrast enhancement.
Conclusions
Classifying adnexal masses is essential for the preoperative management of the patients. 3T MRI protocols, in particular diffusion techniques, increase significantly the accuracy of the diagnostic assessment.
