Download The imaging spectrum of the abdominal wall lesions

The imaging spectrum of the abdominal wall lesions
Poster No.:
C-1671
Congress:
ECR 2010
Type:
Educational Exhibit
Topic:
GI Tract
Authors:
Y.-W. Kim , J. H. Yoon , S. S. Cha ; Yangsan/KR, Busan/KR
Keywords:
Abdominal wall, abdominl wall. disease, abdominal wall, mass
DOI:
10.1594/ecr2010/C-1671
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Learning objectives
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To describe the normal anatomy and constituents of the abdominal wall.
To list a broad spectrum of lesions that affects the abdominal wall.
To illustrate a characteristic imaging findings of lesions that occur in the
abdominal wall
Background
The muscles and fascial layers of the abdominal wall support and protect intraperitoneal
contents and abdominal structures are extended to the retroperitoneal space. Various
conditions are involved in the abdominal wall. Abdominal wall lesions can be classified
as nontumorous or tumorous. Nontumorous lesions include congenital lesion (urachal
abnormalities), abdominal wall hernia, inflammation and, infection (abscess,parasitic
infestation), vascular lesions (varix, venous thrombophlebitis), miscellanous conditions
(edema, RT change, hematoma, subcutaneous emphysema). Various types of benign
and malignant neoplasms can be found involving the abdominal wall either arising
primarily from wall structures or secondarily extending into the sinus from the adjacent
organs or retroperitoneum.Tumors involving the abdominal wall can be classified
according to their origins into three subgroups:(a) primary tumors of mesenchymal origin,
(b) retroperitoneal tumors that extend to the abdominal wall (c)hematogenous spread.
Imaging findings OR Procedure details
Normal anatomy of abdominal wall
Page 2 of 44
Fig.: normal anatomy of abdominal wall
References: Y.-W. Kim; Diagnostic Radiology, Pusan National univeristy, College of
Medicine, Yangsan, KOREA, Republic of
Superficial to deep dissection of the anterior abdominal wall
* Superior aspect of arcuate line
: the rectus abdominis muscle is surrounded by three flank muscle
(transverse muscle, internal and external oblique muscle)
* Inferior aspect of arcuate line
: the aponeurosis of the internal oblique muscle and the transversus abdominis
muscle no longer contribute to the posterior aspect of the rectus sheath, the rectus
invested posteriorly only by the thin transversalis fascia from the arcuate line to
the pubic symphysis
Page 3 of 44
Fig.: nomal anatomy schema and normal CT image of abdominal wall
References: Y.-W. Kim; Diagnostic Radiology, Pusan National univeristy, College of
Medicine, Yangsan, KOREA, Republic of
Pathologic condition of abdominal wall
Page 4 of 44
Fig.: pathologic conditions of abdominal wall
References: Y.-W. Kim; Diagnostic Radiology, Pusan National univeristy,
College of Medicine, Yangsan, KOREA, Republic of
Non-tumorous lesion
Congenital lesion (urachal abnormalities)
1. Patent urachus (50%)
: Urine leakage during the neonatal period.
2. Umbilical-urachal sinus (15%)
: Blind dilatation of the urachus at the umbilical end.
Periodic discharge.
Thickened tubular structure along the midline below the umbilicus.
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3. Vesicourachal diverticulum (3-5%)
: Urachus communicate only with the bladder dome.
Mildline cystic lesion just above the anterosuperior aspect of the bladder.
4. Urachal cyst (30%)
: Fluid-filled cavity in the midline lower abdominal wall.
Fig.: The scheama of Urachal lesions
References: Y.-W. Kim; Diagnostic Radiology, Pusan National univeristy, College of
Medicine, Yangsan, KOREA, Republic of
Non-tumorous lesion
Abdominal wall hernia
Abdominal wall hernias are a frequent imaging finding in the abdomen,
approximately 1.5% of the population.
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Most abdominal wall hernias are asymptomatic.
Content
: variety of intraperitoneal structure, including fat, omentum, bowel.
Complication
: incarceration, obstruction, strangulation, ischemia, infarction.
Type
1) Ventral hernia
- midline defect
- lateral defect
- Spigelian hernia(semilunar)
2) Lumbar hernia
3) Incisional hernia
4) Groin hernia
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Fig.: The types of abdominal hernia
References: CIBA TEXT
1. Ventral hernia
All hernias in the anterior and lateral abdominal wall.
1) Midline defects
* Umbilical hernias (M/C) Fig 1
: small, particularly common in women.
high prevalence of incarceration and strangulation.
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* Paraumbilical hernias
: large abdominal defects through the linea alba.
diastasis of the rectus abdominis muscles.
* Epigastric hernias Fig 2
: uncommon.
though the linea alba between the umbilicus and the xyphoid process.
* Hypogastric hernias
: though the linea alba below the umbilicus.
2) Paramedian or lateral defects
: less common.
typically, omentum and short segments of bowel protrusion.
high prevalence of incarceration.
3) Spigelian hernia (lateral ventral or semilunar hernia) Fig 3
- Rare, 1-2% of all hernia.
- Intermittent lower abdominal pain.
- Internal obstruction.
- Hernia in anterolateral aspect of the lower abdomen.
: along the semilunar line formed by fibrous union of the rectus sheath
with the aponeurosis of the transversus abdominalis & oblique
abdominal muscles.
- Congenital weakness in the posterior layer of transversalis fascia
or surgical incision.
2. Lumbar hernia
- Defects in the lumbar muscles or the posterior fascia,
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below the 12th rib and above the iliac crest.
- After surgery (flank incisions in kidney surgery) or trauma.
- Superior (Grynflett-Lesshaft) lumbar triangle (m/c)
: anteriorly by the internal oblique muscle.
superiorly by the 12th rib.
posteriorly by the erector spinal muscle.
- Inferior (petit) lumbar triangle Fig 4
: anteriorly by the external oblique muscle.
inferiory by the iliac crest.
posteriory by the latissimus dorsi muscle.
Fig.: Lumbar hernia
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References: abdominal imaging
3. Incisional hernia Fig 5
- 0.5% ~ 13.9% for most abdominal surgeries.
- Site : midline and paramedian incision.
- Vertical incision > transverse incisions.
- The first 4 months after surgery.
ß a critical period for the healing of transected within the first
postoperative year.
- Risk factor
: old age, obesity, postoperative wound infection, malnutrition,
chronic pulmonary disease, ascities, malignant tumor.
** Parastomal hernia **
: form of incisional hernia.
bowel loops protrusion through the wall defect at the stomal site.
4. Groin hernia
1) Inguinal hernia
- most common type of abdominal wall hernia.
- more common in males than in females.
- children : most commonly indirect type.
the peritoneal extension accompanying the testis fails
to obliterate.
adults : both direct and indirect types.
acquired weakness and dilatation of the internal inguinal ring.
- indirect type Fig 6
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:origin of the deep inguinal ring.
lateral to the inferior epigastic vessels.
direct type Fig 7
: medial to the inferior epigastic vessels.
through a defect in the Hesselbach triangle.
Fig.: The scheama of Haselbach's triangle
References: CIBA text
2) Femoral Hernias
- Medial to the femoral vein & posterior to the inguinal ligament
(at the femoral canal).
- Usually on the right side.
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- More common in females.
- High prevalence of incarceration than inguinal hernia.
,because of the narrowing of the femoral ring.
- US : direct visualization of bowel loops in peristalsis,
the "to and fro" motion of peritoneal fluid within the hernia,
echogenic omental fat.
5. Other hernia
1) Interparietal (interstitial) hernia Fig 8
- Hernia sac located in the fascial planes between the abdominal wall
muscle that does not exit into the subcutaneous tissue.
- Most frequently in the inguinal region.
2) Richter hernia
- Herniation of the antimesenteric wall of the bowel that does not
compromise the entire wall circumference.
- Association with femoral hernia.
3) Littre hernia
- Inguinal hernia that contains a Meckel diverticulum.
Non-tumorous lesion
Infection & Inflammation
(abscess, parasitic infestation)
Focal inflammatory lesions of the anterior abdominal wall can be postoperative, posttraumatic, or spontaneous (DM, immunosuppression). They can also represent extension
of an intra-abdominal process such as abscess or Crohn's disease.
The Goals of Radiology
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1. The inflammatory lesion must be carefully localized.
- subcutanueous abscess : simple incision & drainage.
- deeper lesions : more aggressive therapy.
2. Evidence for underlying causative factors such as Crohn's disease, infected or
perforated tumor, intra-abdominal abscess should be sought.
3. Cellulitis or phlegmon without a well-defined fluid collection must be
differentiated from frank abscess because antibiotic therapy along is inadequate
to cure an abscess.
4. Percutaneous drainage should be offered in appropriately selected cases.
1. Abscess Fig 9
- Ovoid or spindle shaped à progressively more mass like.
Displacement of liver, spleen, bladder.
** cellulitis & phlegmon
: ill-defined margins, with exception of any margin sharply defined by
a fascial plane.
2. Necrotizing fasciitis Fig 10
- Rare form of aggressive soft tissue infection.
- Risk factor : diabetics, alcoholics.
- Underlying infection in lower genitourinary tract or soft tissues of the
perianal region, blunt or penetrating trauma, surgery, venous stasis,
decubitus ulcer.
- Mortality : 20-50%.
- Imaging finding
: soft tissue gas (radiologic hallmark).
3. Actinomycosis
- Actinomycetes : anaerobic gram-positive filamentous bacteria
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generally a polymicrobial infection.
- Direct inoculation at trauma, intra-abdominal source, blood-borne inf.
- Risk factor : DM, steroid therapy, neoplasm.
- Involvement site : the musculo-aponeurotic layer of the abdominal wall.
- Imaging finding (CT)
: non-specific inflammation.
infiltrative lesion with heterogeneous attenuation.
various contrast enhancement.
4. Sparganosis Fig 11
- Rare disease, but sporadically detected throughout the world.
- Larval cestode diesease.
: infection with the plerocercoid of the genus spirometra.
- Slow-growing, sometimes migratory, subcutaneous mass.
- Imaging finding
1) Plane radiographs : calcification.
2) Sonography
: linear echogenicity with "dot and dash" pattern.
3) CT & MR
: conglomerated cystic lesions.
reactive change in the adjacent soft tissue.
ring enhanced nodule.
Non-tumorous lesion
Vascular lesions (varix, venous thrombophlebitis)
1. Abdominal varix Fig 12
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- Cause : Portal hypertension, saphenous varices, varicoceles.
- The paraumbilical vein arise from the left portal vein.
* anastomose with the superior epigastric or internal thoracic veins.
à drain into the SVC.
* anastomose with the inferior epigastric vein.
à drain into the IVC through the external iliac vein.
- Imaging finding
: enlargement of the superficial abdominal wall veins (caput medusae).
1) Ultrasonography : compressible and typical venous Doppler characteristics.
2) CT : circular or tubular structures more than 2 mm in diameter
2. Mondor's disease (Superficial thrombophlebitis) Fig 13
- Location : mammary region (M/C), lateral thoracic,
thoracoepigastric, superior epigastric vein.
- Etiology : unclear,
direct trauma to vein or pressure on lateral thoracic vein
causing venous stasis.
- Risk factor : breast surgery or biopsy, inflammation, cancer or trauma.
- Treatment : Self-limiting condition, antiinflammatory and analgesic drugs.
- Palpable cord like mass with pain.
- Imaging finding (Ultrasonography)
: superficialy located, long, tubular, anechoic structure.
beaded appearance.
no any flow on color or spectral Doppler.
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Non-tumorous lesion
Miscellanous conditions
1. Hematoma Fig 14
- Trauma to the abdominal wall.
secondary to disorders of coagulation, blood dyscrasia,
degenerative vascular diseases.
- Imaging finding : high attenuation on unenhanced images.
lack of enhancement.
resolution on follow-up studies.
** Rectus sheath hematoma **
: above arcuate line-no across the midline due to linear alba.
(ovoid transversely and biconcave in the long axis.
: below arcuate line - forming large mass.
2. Vascular Grafts
- Axillary-femoral bypass
: parellel to the long axis of the body, along the lateral abdominal wall.
- Femoral-femoral grafts
: cross the lower abdomen just above the symphsis pubis.
- Patency of these grafts.
: palpation, confirmation by Doppler utrasound.
3. Calcifications
- Cause : hypercalcemic state, dermatomyositis, idiopathic calcinosis,
Ehlers-Danlos syndrome, injection granuloma,
epidermolysis bullosa.
4. Subcutaneous gas Fig 15
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-Cause : trauma or surgery (M/C),
infection, ruptured viscus.
Tumorous lesion
Primary tumors of mesenchymal origin
Fig.: The classification of primary tumor of mesenchymal origin
References: Y.-W. Kim; Diagnostic Radiology, Pusan National univeristy,
College of Medicine, Yangsan, KOREA, Republic of
Benign tumor
1. Lipoma Fig 16
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- Most common soft-tissue neoplasm.
- Asymptomatic.
- 50-70 years of age, most frequent in the obese.
- Discrete mobile palpable doughy, solitary soft-tissue mass.
-Imaging finding
1) Sonography
: hyperechoic mass.
heterogeneity ß septa or other nonlipomatous components.
2) CT
: mass of homogeneous adipose tissue.
non enhancement.
slightly enhancement of multiple thin septa.
3) MR
: low signal intensity on fat-suppressed T1-weighted MR image
2. Hemangioma
- Most common tumor of infancy.
- Color : from a vivid crimson to bright scarlet to a bluish hue.
- Pain ß enlarging hemangiomas or those with spontaneous thrombosis.
-Imaging finding
1) Radiography
: phleboliths.
2) CT
: poorly defined mass with an attenuation approximating that of
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skeletal muscle
3) MR
: intermediate signal intensity on T1WI.
marked hyperintensity on T2WI.
signal intensity voids ß rapidly flowing blood
3. Subcutaneous neurofibroma Fig 17
- More than 5% of all benign soft-tissue tumors.
- Adolescence in patients with NF1(60%-90% of affected patients).
- Slow-growing neoplasms that originate from a nerve.
- Type : Localized (90%), diffuse, plexiform.
- Soft, mobile, discrete nodules.
- Imaging finding
1) CT : focal subcutaneous nodules with soft-tissue attenuation.
often numerous.
occasionally, very low attenuation (5-15 HU).
** D/Dx : sebaceous cysts or epidermal inclusion cysts.
2) MR : targetlike appearance on T2WI.
ß central zone : highly cellular component (low SI).
peripheral zone : abundant stromal material (high SI).
markedly enhancement of central part.
4. Endometrioma Fig 18
- Functioning endometrial tissue outside the uterine cavity.
- Two leading theories.
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1) Mesenchymal cells with retained multipotential may, under the
proper circumstances, undergo metaplasia into endometriosis.
2) Endometrial cells may be transported to ectopic sites forming an
endometrioma.
- Up to 15% of menstruating women.
- After pelvic surgery (weeks to years after surgery) or spontaneously.
- Cyclic pain associated with menses or noncyclic abdominal pain.
- Imaging finding : non-specific
1) US : well defined hypoechoic solid masses (M/C), cystic masses,
complex cystic and solid masses.
2) CT &MRI : non-specific solid enhancing mass.
5. Desmoid tumor Fig 19
(musculoaponeurotic fibromatoses, aggressive fibromatosis)
- Most common primary neoplasm of abdominal wall.
- Low-grade, non-metastasizing variant of fibrosarcoma.
- Risk factor : child bearing aged woman, op. scar, Gardner's syndrome.
- Local recurrence is characteristic.
- Location : rectus abdominis (not cross the midline of the abdomen),
internal oblique musculoaponeurotic structures.
- Imaging finding
1) US : well-defined, often hypoechoic.
2) CT : hyperdense compared with muscle.
3) MR : signal intensity less than or equal to that of muscle on T1WI.
variable SI (often low SI ß high collagen content) on T2WI.
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6. Leiomyosarcoma Fig 20
- Less than 5% of superficial soft-tissue sarcomas.
- Most commonly in men aged 50-70 years.
- Children & young adults (age <25 years).
: association of Epstein-Barr virus.
- Frequently painful.
- Solitary lesions (M/C).
- Imaging finding
1) CT : soft tissue attenuation with areas of necrotic or cystic change.
2) MR : low signal intensity on T1WI.
high signal intensity on T2WI.
7. Rhabdomyosarcoma
- High-grade sarcomas characterized by skeletal muscle differentiation.
- Younger than 45 years of age.
- Histologic subtypes.
: embryonal, alveolar, pleomorphic.
- Imaging finding
1) CT : hyperdense compared with muscle.
3) MR : signal intensity less than or equal to that of muscle on T1WI.
variable SI (often low SI ß high collagen content) on T2WI.
Metastasis
Metastatic disease
- Direct invasion by intraabdominal lesions.
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** iatrogenic form : indwelling drain, percutaneous biopsy.
- Vascular dissemination.
- Primary lesion : melanoma, lung, renal, ovarian cancer.
Images for this section:
Fig. 1: Fig. 73-year-old women with left renal cell carcinoma A-B. Axial contrastenhanced CT scan shows an umbilical hernia containing omental fat without evidence
of strangulation (arrows).
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Fig. 2: Fig. 51-year-old women with subtotal gastrectomy due to stomach cancer who
presented with epigastic mass A-B. Axial contrast-enhanced CT scan shows midline
defect in anterior abdominal wall with diastasis of rectus muscles and protrusion of
small bowel (arrows). C-D. Sagital reformatted MDCT scan shows small bowel herniation
between xiphoid process and umbilicus (arrowhead), consistent with epigastic hernia .
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Fig. 3: 63-year-old women total cystectomy with ileal conduit due to bladder cancer
A-D Axial contrast-enhanced CT scan show an spigelian hernia (incisonal type). Note
the extensive herniation of the mesentery, transeverse colon, and ileal conduit (arrow)
through the a peritoneal defect at the lateral border of the right rectus muscle (*).
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Fig. 4: 58-year-old men with previous left frank trauma history A-B. Axial contrastenhanced CT scan shows protrusion of small bowel loops into left inferior lumbar triangle
(arrow) above iliac crest (*), consistent with inferior lumbar (Petit's) incisional hernia.
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Fig. 5: 73-year-old women with history of cholecystectomy A-B. Axial contrast-enhanced
CT scan shows abnormal protrusion of colon (arrow) and left hepatic lobe (arrowhead)
through abdominal wall defect, consistent with incisional hernia.
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Fig. 6: 77-year-old men with acute cholecystitis A-B. Axial contrast-enhanced CT scan
shows the loop of bowel (arrow) lying lateral to the inferior epigastric vessels. Its location
indicates that this is a indirect hernia.
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Fig. 7: 59-year-old men with lower abdominal pain A-B. Axial contrast-enhanced CT
scan shows strangulated right inguinal hernia (arrow). Note the bowel wall thickening,
fat stranding, extraluminal fluid (*), and poor enhancement of herniated bowel, findings
suggest strangulation. C-D Coronal reformatted MDCT scan shows herniated bowel loop
(arrows) lying medial to the inferior epigastic artery (arrowhead), consistent with direct
hernia.
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Fig. 8: 78-year-old men without symptom A-B. Axial contrast-enhanced CT scan
shows interparietal hernia through the right lateral aspect of the abdominal wall (arrow)
containing the omental fat.
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Fig. 9: 60-year-old men with VP shunt A-B. Axial contrast-enhanced CT scan shows
abscess (arrow) in subcutaneous fat layer of left abdominal wall along V-P shunt
(arrowhead).
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Fig. 10: 75-year-old women with renal infarction A-B. Axial contrast-enhanced CT scan
shows inflammation (arrow) and multiple gas bubbles (arrowhead) in subcutaneous
tissue of right anterior abdominal wall, consistent with necrotizing fasciitis.
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Fig. 11: 71-year-old men with palpable mass in right inguinal area A-B. Ultrasonography
shows subcutaneous hypoechoic elongated (arrows) and ovoid nodules (arrowheads) in
anterior abdominal wall. C-D. Axial contrast-enhanced CT scan shows serpentine nodular
lesions with minimal enhancement in subcutaneous fatty layer of right inguinal area.
Results of biopsy confirmed the sparganosis.
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Fig. 12: 49-year-old women with liver cirrhosis A-D. Axial contrast-enhanced CT scan
shows the paraumbilical vein (arrow) as it extends superiorly and inferiorly to the anterior
abdominal wall (arrowhead). The paraumbilical vein arises from the left portal vein (*).
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Fig. 13: 55-year-old women with palpable mass in left lower abdomen A. Longitudinal and
B.transverse ultrasonography shows tubular beaded structure (arrow) consistent with
Mondor's disease (superficial thrombophlebitis).
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Fig. 14: 75-year-old women with VP shunt A. Unenhanced axial CT scan shows
hyperattenuating mass like lesion in subcutaneous fat of right anterior abdominal wall,
along the VP shunt catheter. B. Enhanced axial CT scan shows lack-enhancement of the
lesion, consistent with hematoma.
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Fig. 15: 49-year-old men with traffic accident A-B. Axial unenhanced CT scan shows
free gas dissecting into the abdominal and chest wall (arrow) . The pneumothorax (*) is
also seen.
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Fig. 16: 82-year-old men with painless palpable mass in right abdominal wall. A-B. Axial
contrast enhanced CT scan shows well-defined mass (arrow) with same attenuation as
fat in right abdominal wall, consistent with lipoma.
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Fig. 17: 67-year-old men with known neurofibromatosis I. A-B. Axial contrast enhanced
CT scan shows well-defined, low-attenuation subcutaneous neurofibromas in abdominal
wall (arrow) with large, mutilobulated mass (arrowhead) in peritoneal cavity, consistent
with plexiform neurofibroma.
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Fig. 18: 47-year-old women with lower abdominal wall mass A-B. Axial unenhanced CT
scan shows well-defined mass (arrow) in subcutaneous layer of lower anterior abdomen
to be isodense to muscular tissue with surrounding fat stranding. C-D Axial enhanced CT
scan shows slightly enhancement of lesion with focal cystic portion (arrowhead).
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Fig. 19: 57-year-old men with lower abdominal wall mass A. Axial precontrast CT scan
shows a well-defined mass of low attenuation relative to muscle in the left rectus muscle
(arrows). B. Axial contrast-enhanced CT scan shows minimal enhancement of the mass
with central poor enhancing area (*). Histological findings confirmed the diagnosis of
desmoid tumor. C-D 4months after resection. Axial T2WI(A) and T1WI(B) shows desmoid
tumor in left psoas muscle (arrows).
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Fig. 20: 60-year-old men with general weakness A-B. Axial contrast enhanced CT scan
shows rhadomyosarcoma, alveolar type (arrow) in umbilical area that invaded adipose
tissue and fascia.
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Conclusion
The diagnosis of abdominal wall lesions relies on a multimodality imaging approach
including ultrasonography (US), CT, magnetic resonance (MR) imaging, and
angiography. We illustrate a broad spectrum of pathologic lesions affecting the abdominal
wall.
Personal Information
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