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Download Imaging of the Female Pelvis: Evaluation of a Submucosal Rectal Mass
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Lauren Goldstein, HMS III May 2006 Gillian Lieberman, MD Imaging of the Female Pelvis: Evaluation of a Submucosal Rectal Mass Lauren Goldstein, HMS III Gillian Lieberman, MD Lauren Goldstein, HMS III Gillian Lieberman, MD Our Patient: History of Present Illness November 2005 51 yo F with history of breast cancer undergoes screening colonoscopy Submucosal lesion noted above rectum at junction of rectosigmoid Lesion biopsied & tattooed Biopsy results were benign/nondiagnostic 2 Lauren Goldstein, HMS III Gillian Lieberman, MD Submucosal Lesion at Endoscopy Companion Patient #1: Representative image from sigmoidoscopy of patient with same lesion as our patient. Source: AbuAbu-Hamda and Erickson. Bumps in the Colon: Utility of EUS for Colonic Submucosal Submucosal Masses. Visible Human Journal of Endoscopy. 2003. 3 Lauren Goldstein, HMS III Gillian Lieberman, MD Our Patient: Pertinent History Past medical history Gynecologic history stage I breast cancer s/p left lumpectomy 1997, lymph node dissection (0/13 positive), and radiation therapy HTN, hypercholesterolemia, morbid obesity, GERD Cesarean section 1991, other history unavailable Smoker Family history no family history of colorectal carcinoma or IBD family history of gynecologic malignancy (not specified) 4 Lauren Goldstein, HMS III Gillian Lieberman, MD Our Patient: Review of Systems No bright red blood per rectum, no melena No changes in stool caliber No nausea, vomiting, diarrhea No abdominal pain Irregular vaginal bleeding No fever, chills, sweats, weight loss 5 Lauren Goldstein, HMS III Gillian Lieberman, MD Submucosal Rectal Mass Mass or mass-like lesion that protrudes into lumen of GI tract may be soft tissue, fluid, or air Is covered with normal overlying GI mucosa May be intramural: originating from within GI tract wall extramural: caused by external compression from nearby structures 6 Lauren Goldstein, HMS III Gillian Lieberman, MD Layers of the Rectal Wall Source: AbuAbu-Hamda and Erickson. Bumps in the Colon: Utility of EUS for Colonic Submucosal Submucosal Masses. Visible Human Journal of Endoscopy. 2003. 7 Lauren Goldstein, HMS III Gillian Lieberman, MD Differential Diagnosis: Intramural Mass Lipoma Carcinoid Lymphoma GI stromal tumors Metastatic neoplasms Colitis cystic profunda benign dilated mucus-filled submucosal glands Pneumatosis cystoides intestinalis leiomyoma & leiomyosarcoma air in bowel wall Lymphoid polyps Enteric endometriosis or endometrioma 8 Lauren Goldstein, HMS III Gillian Lieberman, MD Differential Diagnosis: Extramural Mass Cervical mass Uterine mass leiomyoma Ovarian mass cervical carcinoma nabothian cyst malignant: ovarian carcinoma benign: functional follicular cysts, single cysts, cystadenoma, dermoid (mature teratoma), endometriomas, polycystic ovaries Cul-de-sac mass endometriosis or endometrioma metastatic deposit lymphadenopathy 9 Lauren Goldstein, HMS III Gillian Lieberman, MD 10 Anatomy of the Female Pelvis – Sagittal View Most dependent area of pelvis: - fluid accumulation - metastasis seeding Source: http://www.oucom.ohiou.edu/dbmshttp://www.oucom.ohiou.edu/dbms-witmer/Downloads/OConnor%20pelvis.pdf Lauren Goldstein, HMS III Gillian Lieberman, MD Anatomy of the Female Pelvis – Axial View Source: http://www.oucom.ohiou.edu/dbmshttp://www.oucom.ohiou.edu/dbms-witmer/Downloads/OConnor%20pelvis.pdf 11 Lauren Goldstein, HMS III Gillian Lieberman, MD Menu of Imaging Tests for the Evaluation of the Female Pelvis Endorectal ultrasound Transvaginal ultrasound MRI Endorectal MRI CT 12 Lauren Goldstein, HMS III Gillian Lieberman, MD Endorectal Ultrasound Used widely in staging of rectal carcinoma to For rectal submucosal lesions, useful to determine whether mass is intramural or extramural determine wall layer from which lesion originates define echotexture of lesion Advantages: assess depth of tumor penetration detect presence of local and regional nodal metastases detect vascular invasion radiation-free, readily available, inexpensive, generally well-tolerated Limitations: requires technical expertise and experience may require anesthesia may not be able to pass probe if lesion stenosing or obstructing 13 Lauren Goldstein, HMS III Gillian Lieberman, MD 14 Endorectal Ultrasound Layers Source: AbuAbu-Hamda and Erickson. Bumps in the Colon: Utility of EUS for Colonic Submucosal Submucosal Masses. Visible Human Journal of Endoscopy. 2003. Lauren Goldstein, HMS III Gillian Lieberman, MD 15 Differentiating Pelvic Masses with EUS Lesion Endosonographic layer Endosonographic features Carcinoid 2nd, 3rd or 4th (often originate in mucosa) Hypoechoic, sharp margins GIST Usually 4th Hypoechoic, heterogenous, sharp margins Pneumotosis cystoides intestinalis 2nd and 3rd Impenetrable to ultrasound. Multiple hyperechoic interfaces just below mucosal layer Lipoma 3rd Hyperechoic Lymphoma 2nd, 3rd or 4th Hypoechoic inhomogeneous mass Endometriosis 4th but can involve all layers as endometriosis invades through colonic wall Usually hypoechoic, may have cystic component Extrinsic organ Extracolonic Appearance of extrinsic organ (vessel, uterus, ovary, etc.) Source: AbuAbu-Hamda and Erickson. Bumps in the Colon: Utility of EUS for Colonic Submucosal Submucosal Masses. Visible Human Journal of Endoscopy. Endoscopy. 2003. Lauren Goldstein, HMS III Gillian Lieberman, MD 16 Submucosal Rectal Masses on EUS Companion Patient #2: Companion Patient #3: Companion Patient #4: Carcinoid GIST (leiomyosarcoma) Pneumatosis coli Companion Patient #5: Companion Patient #6: Lipoma Endometriosis Source: AbuAbu-Hamda and Erickson. Bumps in the Colon: Utility of EUS for Colonic Submucosal Submucosal Masses. Visible Human Journal of Endoscopy. Endoscopy. 2003. Source: http://www.ddc.musc.edu/ddc_pro/pro_development/atlases/EUS/cancer1.htm http://www.ddc.musc.edu/ddc_pro/pro_development/atlases/EUS/cancer1.htm Lauren Goldstein, HMS III Gillian Lieberman, MD Transvaginal Ultrasound Used widely in gynecologic examination of location, size, consistency of lesions of For rectal submucosal lesions, useful to determine whether mass is intramural or extramural define echotexture of lesion provide better visualization of rectovaginal space infiltration and lymph node enlargement than endorectal ultrasound enhance staging accuracy of rectal neoplasms Doppler allows assessment of lesion vascularity Advantages: uterus adnexa radiation-free, readily available, inexpensive, generally well-tolerated Limitations: difficult to evaluate the depth of rectal wall involvement unable to determine exact distance of rectal lesions from the anal margin limited field of view renders examination of large or high pelvic masses difficult requires technical expertise and experience 17 Lauren Goldstein, HMS III Gillian Lieberman, MD 18 TVUS Layers R = rectum MM = mucosa and submucosa MP = muscularis propria PVF = posterior vaginal fornix C = cervix Source: Bazot et al. Transvaginal sonography and rectal endoscopic sonography for the assessment of pelvic endometriosis: a preliminary comparison. comparison. Human Reproduction 2003; 18: 16861686-1692. Lauren Goldstein, HMS III Gillian Lieberman, MD 19 Selected Pelvic Lesions on TVUS Companion Patient #7: Companion Patient #8: Rectal leiomyosarcoma Posterior pelvic endometriosis Source: Serafini et al. Transvaginal ultrasonography of nongynecologic pelvic lesions. Abdom Imaging 2001;26:540– 2001;26:540–549. Source: Bazot et al. Transvaginal sonography and rectal endoscopic sonography for the assessment of pelvic endometriosis: a preliminary comparison. comparison. Human Reproduction 2003; 18: 16861692. 1686 Lauren Goldstein, HMS III Gillian Lieberman, MD 20 MRI Multiplanar imaging & superior soft tissue contrast resolution allows determination of origin of pelvic mass differentiation between intramural and extramural lesions characterization of pelvic mass staging of gynecologic malignancies, especially nodal involvement Advantages: radiation-free Limitations: expensive, contraindicated in some patients, not as widely available Lauren Goldstein, HMS III Gillian Lieberman, MD 21 T2 MRI of Normal Female Pelvis Sagittal view Axial view Axial view e = endometrium short arrows = uterine fundus short arrows = vagina white arrows = junctional zone long arrows = ovaries long arrows = puborectalis component of levator ani black arrows = myometrium incidental finding= bladder fold Source: Fielding, Julia. MR Imaging of the Female Pelvis. Radiol Clin North Am. Am. 2003; 41: 179179-192. Lauren Goldstein, HMS III Gillian Lieberman, MD 22 Differentiating Pelvic Masses with MRI Lesion Radiographic features Rectal tumors Intermediate signal on T1 and T2 Uterine leiomyoma Circumscribed, decreased T1 and T2 signal Cellular: intermediate T2 signal, early enhancement Degenerating: heterogeneous high T2 signal intensity necrosis Cervical carcinoma Isointense to normal cervix on T1; hyperintense to normal low signal intensity cervix on T2 With T2 or gad-enhanced T1, can assess extension to vaginal wall (sagittal), to parametrial tissues (axial), and through muscularis propria of rectum (axial) Lymphadenopathy Lymph nodes appear dark against much brighter background pelvic fat on T1 Ovarian massess Benign: follicular cysts (high signal on T2), hemorrhagic cysts (high signal on T1), endometriomas (loss of signal on T2), dermoids (loss of signal on fat-suppressed T1 & on T2), teratomas (fat-fluid level, mural nodules, low signal bony elements), PCOS (multiple bilateral cysts), benign tumors (cystic with fine septations & no solid components) Malignant: cystadenocarcinoma (predominately cystic mass with nodular enhancing wall and thick enhancing septa) Endometriosis Unilocular or multilocular; predominately high signal on T1, low or mixed signal on T2, often with intermediate signal shading on T2 due to shortening of blood products Source: Maldjian and Schnall. Schnall. Magnetic Resonance Imaging of the Uterine Body, Cervix, and Adnexa. Adnexa. Semin Roentgenol. Roentgenol. 1996;31(4):2571996;31(4):257-66. Source: Fielding, Julia. MR Imaging of the Female Pelvis. Radiol Clin North Am. Am. 2003; 41: 179179-192. Lauren Goldstein, HMS III Gillian Lieberman, MD 23 Lesions on MRI Companion Patient #9: Uterine leiomyoma on T2 sagittal (a) and axial (b) Companion Patient #10: Endometriosis on axial T1 (a) and T2 (b) Companion Patient #11: Cervical cancer on T2 sagittal (a) and axial (b) Source: Fielding, Julia. MR Imaging of the Female Pelvis. Radiol Clin North Am. Am. 2003; 41: 179179-192. Lauren Goldstein, HMS III Gillian Lieberman, MD 24 Endorectal MRI Usually combines endorectal coil for local imaging with standard MRI for imaging distant organ involvement Allows assessment of: Advantages: location of rectal tumor depth of invasion presence of nodal metastases >5mm presence of distant metastases radiation-free, generally well-tolerated Limitations: limited field of view renders examination of large or high pelvic masses difficult requires technical expertise and experience may require anesthesia may not be able to pass probe if lesion stenosing or obstructing Lauren Goldstein, HMS III Gillian Lieberman, MD 25 CT Multiplanar imaging allows determination of origin of pelvic mass differentiation between intramural and extramural lesions characterization of pelvic mass staging of gynecologic malignancies, especially nodal involvement Advantages: widely available, quicker, higher spatial resolution than MR Limitations: radiation exposure, expensive Lauren Goldstein, HMS III Gillian Lieberman, MD CT of Normal Female Pelvis – Axial View uterus rectum Source: Female Pelvis CT http://www.dartmouth.edu/~anatomy/pelvis/labimages/femalepelvisct1.html http://www.dartmouth.edu/~anatomy/pelvis/labimages/femalepelvisct1.html 26 Lauren Goldstein, HMS III Gillian Lieberman, MD 27 Intramural Masses on Axial CT Companion Patient #12: Companion Patient #13: Companion Patient #14: Companion Patient #15: Lymphoid polyps in colon Lipoma in colon: fat attenuation GIST in rectum Pneumatosis cystoides coli: air-filled cysts with localized subserosal air Source: Pickhardt. Pickhardt. Differential Diagnosis of Polypoid Lesions Seen at CT Colonography (Virtual Colonoscopy). RadioGraphics 2004;24:15352004;24:1535-1556. Lauren Goldstein, HMS III Gillian Lieberman, MD 28 Pelvic Masses on Axial CT Companion Patient #16: Companion Patient #17: Parametrial cervical cancer Teratoma: fatty mass with calcification Source: Pannu. Pannu. CT Evaluation of Cervical Cancer: Spectrum of Disease. Radiographics. Radiographics. 2001;21:11552001;21:1155-1168. Source: Hamm. MR imaging and CT of the female pelvis: radiologicradiologic-pathologic correlation. Eur. Radiol. Radiol. 1999; 9, 33-15. Lauren Goldstein, HMS III Gillian Lieberman, MD How were the available imaging modalities employed in the evaluation of our patient? 29 Lauren Goldstein, HMS III Gillian Lieberman, MD Our Patient: OSH Evaluation & Management Records of imaging history at OSH unavailable Flexible sigmoidoscopy at OSH on initial presentation Exploratory laparotomy at OSH on initial presentation appeared that lesion had increased in size mass appeared to emanate from posterior wall of cervix biopsy results = benign/nondiagnostic goal: resect posterior cul-de-sac mass to obtain tissue diagnosis mass could not be identified intra-operatively intra-operative gynecology consult: exam under anesthesia showed mass on cervix, probably projecting into rectal lumen repeat flex sigmoidoscopy with tattoo of lesion due to concern that growing mass might cause rectal obstruction, completed Hartman’s procedure w/end sigmoid colostomy Patient referred to DFCI/BWH for further evaluation and management 30 Lauren Goldstein, HMS III Gillian Lieberman, MD 31 Our Patient: MRI one month after initial presentation Sagittal View – T1 mass arising from posterior aspect of the cervix, hypointense on T1 second anterior cervical lesion, bright on T1 (does not enhance on T2) Source: PACS, BWH Lauren Goldstein, HMS III Gillian Lieberman, MD 32 Our Patient: MRI one month after initial presentation Axial View – T2 mass in the posterior cul-desac 2.8 cm diameter rim hypointense on T2 centrally hyperintense on T2 spiculation & invasion of right parametrial tissue Source: PACS, BWH Lauren Goldstein, HMS III Gillian Lieberman, MD 33 Our Patient: MRI one month after initial presentation Axial View – T1 thickening of right uterosacral ligament Source: PACS, BWH Lauren Goldstein, HMS III Gillian Lieberman, MD 34 Our Patient: MRI one month after initial presentation Axial View – T1 Post-Gadolinium mass enhances with IV gadolinium Source: PACS, BWH Lauren Goldstein, HMS III Gillian Lieberman, MD Our Patient: Summary of MRI Findings Posterior cervical mass, gadolinium-enhancing and with central T2 hyperintensity and rim hypointensity, concerning for Several enlarged lymph nodes on both sides, largest 1.4 cm in right common iliac lymph node chain, concerning for metastatic colon cancer deposit post-surgical inflammation Anterior cervical mass, non-enhancing, concerning for primary cervical neoplasm local or metastatic cancer recurrence degenerating leiomyoma metastatic deposit nabothian cyst Extensive infiltration of mesenteric fat in anterior pelvis Normal ovaries Normal liver 35 Lauren Goldstein, HMS III Gillian Lieberman, MD 36 Our Patient: TVUS ten days later Sagittal View Heterogenous irregular mass in posterior cul-de-sac, 3.5 x 3.3 x 2.6 cm Source: PACS, BWH Lauren Goldstein, HMS III Gillian Lieberman, MD 37 Our Patient: TVUS ten days later Coronal View Heterogenous irregular mass in posterior cul-de-sac, 3.5 x 3.3 x 2.6 cm Source: PACS, BWH Lauren Goldstein, HMS III Gillian Lieberman, MD Our Patient: Further Evaluation & Management Gynecologic consult on first presentation TVUS-guided biopsy Pap smears and cervical biopsies negative Follow-up radiology consult benign, with some fibrotic connective tissue elements, potentially suggestive of leiomyoma lesion likely benign, potentially degenerating leiomyoma Exploratory laparotomy two months later goals biopsy mass to obtain tissue diagnosis to rule out malignancy reverse colostomy identified nodular mass between the cervix and the rectum, particularly along the right uterosacral ligament, stony hard on palpation biopsy results consistent with endometriosis 38 Lauren Goldstein, HMS III Gillian Lieberman, MD 39 Conclusions All imaging modalities assist in determining whether rectal submucosal lesion is intramural or extramural Endorectal US & endorectal MRI Transvaginal US best modalities for evaluating rectal intramural lesions best modality for evaluating extramural lesions involving uterus & adnexa good modality for visualization of rectovaginal space infiltration and lymph node enlargement MRI & CT best modalities for determination of origin of pelvic mass & staging of gynecologic malignancies, especially nodal involvement MRI better for lesion characterization due to superior soft tissue differentiation MRI better due to lack of ionizing radiation Lauren Goldstein, HMS III Gillian Lieberman, MD References Books and Journal Articles Abu-Hamda and Erickson. Bumps in the Colon: Utility of EUS for Colonic Submucosal Masses. Visible Human Journal of Endoscopy. 2003. Bazot et al. Transvaginal sonography and rectal endoscopic sonography for the assessment of pelvic endometriosis: a preliminary comparison. Human Reproduction 2003;18: 1686-1692. Damani and Wilson. Nongynecologic Applications of Transvaginal US. Radiographics. 1999;19:S179S200. Fielding. MR Imaging of the Female Pelvis. Radiol Clin North Am. 2003; 41: 179-192. Greenfield et al. Surgery: Scientific Principles and Practice. 2001. Hamm. MR imaging and CT of the female pelvis: radiologic-pathologic correlation. Eur. Radiol. 1999; 9, 3-15. Iyer. Imaging of Gynecologic Malignancy. Semin Roentgenol. 2004;39(3):428-436. Maldjian and Schnall. Magnetic Resonance Imaging of the Uterine Body, Cervix, and Adnexa. Semin Roentgenol. 1996;31(4):257-66. Pannu. CT Evaluation of Cervical Cancer: Spectrum of Disease. Radiographics. 2001;21:1155-1168. Pickhardt. Differential Diagnosis of Polypoid Lesions Seen at CT Colonography (Virtual Colonoscopy). RadioGraphics 2004;24:1535-1556. Reeder. Gamuts in Radiology, 4th Edition. 2003. Serafini et al. Transvaginal ultrasonography of nongynecologic pelvic lesions. Abdom Imaging 2001;26:540–549. Sudakoff et al. Sonography of Anorectal, Rectal, and Perirectal Abnormalities. AJR 2002; 179:131136. Zagoria and Wolfman. Magnetic Resonance Imaging of Colorectal Cancer. Semin Roentgenol. 1996;31(2):162-165. 40 Lauren Goldstein, HMS III Gillian Lieberman, MD 41 References Websites Penman and Williams. Cancer Staging: Esophageal, Gastric & Rectal Cancer. http://www.ddc.musc.edu/ddc_pro/pro_development/atlases/EUS/cancer1.htm Cervical Cancer. http://www.emedicine.com/radio/topic140.htm Female Pelvis CT. http://www.dartmouth.edu/~anatomy/pelvis/labimages/femalepelvisct1.html http://www.acupath.com/case.php http://www.endoatlas.com/co_mt_09.html http://www.oucom.ohiou.edu/dbms-witmer/Downloads/OConnor%20pelvis.pdf Lauren Goldstein, HMS III Gillian Lieberman, MD Special Thanks To Gillian Lieberman, MD Mary Kwaan, MD Pamela Lepkowski Larry Barbaras 42
